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-ARTIN&3PRINZLAND0ETER2'ALLE $IFFERENTIALDIAGNOSISOFHUMANHEPATITIS   4HOMAS,ONGERICHAND0ETER3CHIRMACHER #OMPARATIVEPATHOLOGY  3TEPHAN5RBANAND5LRIKE0ROTZER (EPATITIS"VIRUS,ESSONSLEARNEDFROMTHEVIRUSLIFECYCLE  2ALF"ARTENSCHLAGER 'ANG,ONGAND$ARIUS-ORADPOUR #HRONICHEPATITIS#0ORTRAITOFASILENTEPIDEMIC ANDTHEETIOLOGICAGENT  -ANFRED(7OLFFAND!XEL3CHMIDT (EPATITIS!INFECTION  !XEL3CHMIDTAND-ANFRED(7OLFF (EPATITIS%INFECTION  (ILMAR7ISPLINGHOFFAND$ARRYN,!PPLETON "ACTERIALINFECTIONSOFTHELIVER  !CHIM(ARDERAND(EINZ-EHLHORN #OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITES ORTHEIRDISTINCTLIFECYCLESTAGES  3TEFAN,àTHAND!NSGAR7,OHSE !UTOIMMUNEHEPATITISINHUMANS  

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,ISTOFCONTRIBUTORS $ARRYN,!PPLETON $EPARTMENTFOR)NTERNAL-EDICINE 6IRGINIA#OMMON WEALTH5NIVERSITY 2ICHMOND 6! 53!E MAILDAPPLETON MCVH VCUEDU 2ALF"ARTENSCHLAGER $EPARTMENTOF-OLECULAR6IROLOGY 5NIVERSITYOF(EI DELBERG )M.EUENHEIMER&ELD (EIDELBERG 'ERMANY E MAILRALF?BARTENSCHLAGER MEDUNI HEIDELBERGDE +AI$ALLMEIER 5NIVERSITY(OSPITAL&REIBURG )NTERNAL-EDICINE))-OLECU LAR"IOLOGY (UGSTETTER3TR &REIBURG 'ERMANY E MAILKAIDALLMEIER WEBDE +ATJA$ETERDING $EPARTMENTOF'ASTROENTEROLOGY (EPATOLOGYAND%NDO CRINOLOGY (ANNOVER-EDICAL3CHOOL #ARL .EUBERG 3TR (ANNO VER 'ERMANYE MAILDETERDINGKATJA MH HANNOVERDE !NDY % $URHAM 4HE ,IPHOOK %QUINE (OSPITAL &OREST -ERE ,IPHOOK (AMPSHIRE '5*' 5NITED+INGDOME MAILANDY THELEHCOUK 0ETER 2 'ALLE *OHANNES 'UTENBERG 5NIVERSITËT  -EDIZINISCHE +LINIK ,ANGENBECKSTRASSE -AINZ 'ERMANY E MAILGALLE UNI MAINZDE *OHN,'ERIN $EPARTMENTOF-OLECULAR6IROLOGYAND)MMUNOLOGY 'EOR GETOWN5NIVERSITY-EDICAL3CHOOL 7ASHINGTON $# 53! !CHIM(ARDER "AYER(EALTH#ARE!' !NIMAL(EALTH 2$ 0ARASITICIDES !LFRED .OBEL 3TR -ONHEIM 'ERMANY E MAILACHIMHARDER BAYERHEALTHCARECOM 7ILLIAM % (ORNBUCKLE $EPARTMENT OF #LINICAL 3CIENCES .EW9ORK 3TATE #OLLEGE OF 6ETERINARY -EDICINE #ORNELL 5NIVERSITY )THACA .9  53! 0ERCY!+NOLLE )NSTITUTEOF-OLECULAR-EDICINEAND%XPERIMENTAL)MMU NOLOGY 5NIVERSITY (OSPITAL "ONN &RIEDRICH 7ILHELM 5NIVERSITY "ONN 3IGMUND &REUD 3TR "ONN 'ERMANY E MAILPERCYKNOLLE UKBUNI BONNDE !NSGAR7 ,OHSE ) $EPARTMENT OF -EDICINE 5NIVERSITY -EDICAL #ENTER (AMBURG %PPENDORF -ARTINISTR (AMBURG 'ERMANY E MAILALOHSE UKEUNI HAMBURGDE 'ANG,ONG $EPARTMENTOF-OLECULAR6IROLOGY 5NIVERSITYOF(EIDELBERG )M.EUENHEIMER&ELD (EIDELBERG 'ERMANY E MAILGANG?LONG MEDUNI HEIDELBERGDE

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4HOMAS ,ONGERICH )NSTITUTE OF 0ATHOLOGY 5NIVERSITY OF (EIDELBERG )M .EUENHEIMER&ELD (EIDELBERG 'ERMANY E MAILTHOMASLONGERICH MEDUNI HEIDELBERGDE 3TEFAN,àTH )$EPARTMENTOF-EDICINE 5NIVERSITY-EDICAL#ENTER(AM BURG %PPENDORF -ARTINISTR (AMBURG 'ERMANY E MAILSLUETH UKEDE -ICHAEL0-ANNS $EPARTMENTOF'ASTROENTEROLOGY (EPATOLOGYAND%NDO CRINOLOGY (ANNOVER-EDICAL3CHOOL #ARL .EUBERG 3TR (ANNO VER 'ERMANYE MAILMANNSMICHAEL MH HANNOVERDE (EINZ -EHLHORN $EPARTMENT OF 0ARASITOLOGY (EINRICH (EINE 5NIVERSITY $àSSELDORF 'ERMANYE MAILMEHLHORN UNI DUESSELDORFDE $ARIUS-ORADPOUR $IVISIONOF'ASTROENTEROLOGYAND(EPATOLOGY #ENTRE (OSPITALIER5NIVERSITAIRE6AUDOIS 5NIVERSITYOF,AUSANNE ,AUSANNE 3WITZERLANDE MAILDARIUSMORADPOUR CHURCH -ICHAEL.ASSAL 5NIVERSITY(OSPITAL&REIBURG )NTERNAL-EDICINE))-OLECU LAR"IOLOGY (UGSTETTER3TR &REIBURG 'ERMANY E MAILNASSAL UKLUNI FREIBURGDE 5LRIKE 0ROTZER )NSTITUTE OF6IROLOGY 4ECHNICAL 5NIVERSITY -UNICH (ELM HOLTZ #ENTER -UNICH n .ATIONAL 2ESEARCH #ENTER FOR %NVIRONMENTAL (EALTH 4OGERSTR -àNCHEN 'ERMANY E MAILPROTZER VIROLOGIETUMDE *AN 2OTHUIZEN $EPARTMENT OF #LINICAL 3CIENCES OF #OMPANION !NIMALS &ACULTY OF6ETERINARY -EDICINE 5NIVERSITY 5TRECHT 9ALELAAN   4$5TRECHT 4HE.ETHERLANDS E MAILJROTHUIZEN VETUUNL 0ETER 3CHIRMACHER )NSTITUTE OF 0ATHOLOGY 5NIVERSITY OF (EIDELBERG )M .EUENHEIMER&ELD (EIDELBERG 'ERMANY E MAILPETERSCHIRMACHER MEDUNI HEIDELBERGDE !XEL3CHMIDT 0RIVATE5NIVERSITYOF7ITTEN(ERDECKE &ACULTYOF-EDICINE !LFRED (ERRHAUSEN 3TR 7ITTEN 'ERMANY E MAILAXEL T ONLINEDE -ARTIN&3PRINZL *OHANNES'UTENBERG 5NIVERSITËT -EDIZINISCHE+LINIK ,ANGENBECKSTRASSE -AINZ 'ERMANY E MAILSPRINZL  MEDKLINIKUNI MAINZDE $IRK3TABENOW )NSTITUTEOF-OLECULAR-EDICINEAND%XPERIMENTAL)MMU NOLOGY 5NIVERSITY (OSPITAL "ONN &RIEDRICH 7ILHELM 5NIVERSITY "ONN 3IGMUND &REUD 3TR "ONN 'ERMANY E MAILDIRKSTABENOW UKBUNI BONNDE "UD#4ENNANT $EPARTMENTOF#LINICAL3CIENCES .EW9ORK3TATE#OLLEGEOF 6ETERINARY-EDICINE #ORNELL5NIVERSITY )THACA .9  53! E MAILBCT CORNELLEDU 3TEPHAN 5RBAN $EPARTMENT OF -OLECULAR6IROLOGY /TTO -EYERHOF :EN TRUM 5NIVERSITYOF(EIDELBERG )M.EUENHEIMER&ELD (EIDEL BERG 'ERMANYE MAILSTEPHANURBAN MEDUNI HEIDELBERGDE

,ISTOFCONTRIBUTORS

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0REFACE (EPATITISISANINFLAMMATIONOFTHELIVERTISSUECAUSINGHEPATOCELLULARINJURY WHICHMAYHAVEDIFFERENTAETIOLOGIES)NHUMANS ACUTEANDCHRONICHEPATITIS ANDHEPATITIS RELATEDDISEASESSUCHASLIVERFAILURE LIVERCIRRHOSISANDHEPA TOCELLULARCARCINOMAAREAMONGTHEMOSTIMPORTANTCAUSESFORDISABILITIES AND DEATH 7HEREAS THE REACTION OF THE LIVER TISSUE IS RELATIVELY UNIFORM THECAUSESFORHEPATOCELLULARINJURYAREHETEROGENEOUSANDINCLUDEVIRUSES TOXINS RADIATION INJURYANDDRUGSBUTALSOBACTERIA PARASITESANDAUTOIM MUNEREACTIONS )NTHISVOLUMEOF"IRKHËUSER!DVANCESIN)NFECTIOUS$ISEASESWEREVIEW TODAYS KNOWLEDGE ABOUT HEPATITIS WITH EMPHASIS ON COMPARATIVE ASPECTS BETWEENHEPATITISINHUMANSANDANIMALS BUTALSOBETWEENDIFFERENTETIO LOGICALAGENTS 4HISBOOKISDEDICATEDTO(EINZ3CHALLERWHODEDICATEDMOSTOFHISLIFE AS A SCIENTIST TO THE UNDERSTANDING OF THE INTERACTION BETWEEN HEPATITIS " VIRUSESANDTHEIRHOSTS (EINZISAPERSONALITYWHOMANAGEDADIFFICULTTHINGTODOHESUCCESSFUL LYCROSSEDBARRIERS(EWORKEDASANENTHUSIASTICSCIENTISTCROSSINGCLASSICAL BARRIERSBETWEENCHEMISTRY BIOLOGYANDMEDICINE(EGUIDEDSCIENTISTSAND STUDENTSANDHELPEDTOFORMNEWWAYSOFTHINKINGANDORGANIZINGACADEMIC RESEARCHIN'ERMANY!REMARKABLENUMBEROFHISFELLOWSMADEOUTSTAND INGCARRIERSINDIFFERENTSCIENTIFICAREAS &URTHERMORE HEHASINSIGNIFICANTWAYSENHANCEDOURUNDERSTANDINGOF THEPATHOGENESISOFHEPATITIS"VIRUSINFECTIONS HASCONTRIBUTEDTOTHEDEVEL OPMENTOFTHECURRENTVACCINE HASIMPROVEDTHECAREOFPATIENTSINFECTED WITHTHEVIRUS ANDHASTRAINEDSOMEOFTHEMOSTDISTINGUISHEDMEMBERSOF THECURRENTGENERATIONOFHEPATOLOGISTSANDVIROLOGISTS "UTHEALSOCROSSEDBORDERSBYSEARCHINGFORAPPLICATIONSOFHISRESEARCH (EISONEOFTHEFEWWHO INADDITIONTOASUCCESSFULACADEMICCAREER HAVE SET THE STAGE FOR A COMMERCIAL SUCCESS STORY n (EINZ WAS A CO FOUNDER OF ONEOFTHEFIRSTCOMPANIESDEDICATEDTOBIOTECHNOLOGY"IOGEN)DEC4HANKS TO HIS MAJOR INPUT AND INTERVENTION THE #ENTER FOR -OLECULAR "IOLOGY (EIDELBERG :-"( AS A BIOMEDICAL RESEARCH CENTER WITH WORLD WIDE REPUTATION WAS FOUNDED ,AST NOT LEAST (EINZ HAS USED THIS SUCCESS FOR A SUSTAINEDSUPPORTOFBIOMEDICALRESEARCHINACADEMICSWITHTHEh#HICAAND (EINZ3CHALLER3TIFTUNGv

XII

0REFACE

(EINZS WORK HAS BEEN CATALYTIC FOR OUR UNDERSTANDING OF HEPATITIS "nONEOFTHEMOSTPREVALENTFORMSOFCHRONICHEPATITIS#ROSSINGBORDERS nARETHERETHATMANY (ERE WEWOULDLIKETOTAKETHEOPPORTUNITYTOTHANK(EINZFORHISDEDI CATIONTOSCIENCEANDWISHHIMALLTHEBESTFORTHEYEARSTOCOME *ANUARY

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!BSTRACT (EPATITIS IS AN INFLAMMATION OF THE LIVER BASED ON DIFFERENT AETIOLOGIES #LINICIANS DIS TINGUISH ACUTE FROM CHRONIC HEPATITIS 0ATHOPHYSIOLOGICAL CHANGES LEAD TO DAMAGE AND HEPATOCELLULAR DEGENERATION 4HE CAUSES FOR HEPATOCELLULAR INJURY ARE HETEROGENEOUS SUCHASVIRUSES TOXINS DRUGS AUTOIMMUNITY CRYPTOGENIC4HELATESTOFFICIALCLASSIFICATION OFCHRONICHEPATITISBYTHE)NTERNATIONAL!SSOCIATIONTHE3TUDYOFTHE,IVER)!3, ;=IS STILLVALIDANDISBASEDON !ETIOLOGY )NFLAMMATORYACTIVITY'RADING &IBROSISSTAGE3TAGING 4HIS CLASSIFICATION HAS BECOME VERY RELEVANT SINCE WE NOWADAYS NOT ONLY DIAGNOSE THE DIFFERENTLIVERDISEASESACCORDINGTOTHEIRAETIOLOGYBUTALSOHAVEDEVELOPEDSPECIFICTREAT MENTSTHATARETARGETINGSPECIFICAETIOLOGIESOFCHRONICLIVERDISEASE/VERLAPSYNDROMES WITHPRIMARYBILIARYCIRRHOSISANDPRIMARYSCLEROSINGCHOLANGITISANDGENETICLIVERDISEASES ADDTOTHECLINICALSPECTRUMOFTHISSYNDROME )N THIS CHAPTER WE WILL DESCRIBE THE DIFFERENT CAUSES OF HEPATITIS THEIR TREATMENT OPTIONSANDDIFFERENTIALDIAGNOSIS

)NTRODUCTION (EPATITIS IS AN INFLAMMATION OF THE LIVER DUE TO VARIOUS REASONS 0ATHOPHYSIOLOGICAL CHANGES LEAD TO HEPATOCELLULAR DAMAGE #AUSES OF THIS HEPATOCELLULARDEGENERATIONAREHETEROGENOUSSUCHASTOXINS DRUGS VIRUSES AND AUTOIMMUNITY 4HE PATHOLOGIC CHANGES DUE TO DIFFERENT AETIOLOGIES SHARE SIMILARITIES THESE INCLUDE LOBULAR DISARRAY INFLAMMATION INVOLVING PORTAL TRACTS AND LOBULES AND HEPATOCELLULAR DEGENERATION IN THE FORM OF BALLOONING AND APOPTOSIS -ICROORGANISMS SUCH AS BACTERIA VIRUSES FUNGI OR PARASITES INDUCE THE SECRETION OF BIOLOGICALLY ACTIVE MOLECULES BY MAC ROPHAGES AFTER PENETRATING THE EPITHELIAL SURFACES OF THE BODY !CTIVATED MACROPHAGES SECRETE CYTOKINES WHICH ARE DEFINED AS PROTEINS RELEASED



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0RIMARYSCLEROSINGCHOLANGITIS 0RIMARY SCLEROSING CHOLANGITIS 03# ALSO IS A CHRONIC CHOLESTACTIC LIVER DISEASE 03# IS CHARACTERISED BY CONCENTRIC OBLITERATIVE FIBROSIS OF INTRA HEPATIC AND EXTRAHEPATIC BILIARY TREE LEADING TO ITS DESTRUCTION AND TO BILIARYCIRRHOSIS; =4HEAETIOLOGYOF03#ISUNCLEAR ALTHOUGHGROW ING EVIDENCE SUPPORTS THAT SEVERAL IMMUNE AND NONE IMMUNE MEDIATED MECHANISM AS WELL AS GENETIC PREDISPOSITION PLAY A SIGNIFICANT ROLE IN DISEASEAETIOPATHOGENESIS4HEREISASTRONGASSOCIATIONBETWEEN03#AND INFLAMMATORYBOWELDISEASEWITHBETWEENn03#PATIENTSOFNORTH ERN %UROPEAN ORIGIN HAVING UNDERLYING INFLAMMATORY BOWEL DISEASE ; = ESPECIALLYULCERATIVECOLITIS4HETRUEPREVALENCEOF03#ISUNKNOWN !LMOSTHALFOFALL03#PATIENTSAREASYMPTOMATICATTHETIMEOFDIAGNOSIS 4HEASYMPTOMATICINDIVIDUALHASINCIDENTALDISCOVERYOFMILDLYABNORMAL LIVERBLOODTESTS4HEPRESENCEOFSYMPTOMSDOESNOTCORRELATEWELLWITH DISEASE SEVERITY &ATIGUE AND PRURITUS ARE THE MOST COMMON SYMPTOMS *AUNDICE ABDOMINALPAINANDWEIGHTLOSSAREUSUALLYPRESENTINTHELATER STAGESOFTHEDISEASE&EVERANDCHILLSMAYBEMANIFESTATIONSOFASCENDING BACTERIALCHOLANGITIS %NDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY REMAINS THE GOLD STANDARDTODIAGNOSELARGEDUCT03#4HEFINDINGOFMULTIFOCALSTRICTURESAND DILATATIONS WITH BEADED APPEARANCE AND OCCASIONAL DIVERTICULAR FORMATION

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INVOLVING THE INTRAHEPATIC ANDOR EXTRAHEPATIC BILIARY TREES CHARACTERISES THE DISEASE ;=4HE CLASSIC LABORATORY FINDING IN PATIENTS WITH 03# IS AN INCREASEDALKALINEPHOSPHATISELEVEL-OSTPATIENTSALSOHAVERAISEDAMINO TRANSFERASES 4HE CLINICAL MANAGEMENT OF 03# PATIENTS SHOULD FOCUS ON ALLEVIATING SYMPTOMS AND COMPLICATIONS OF END STAGE LIVER DISEASE 3EVERAL TREATMENT OPTIONSHAVEBEENSTUDIEDFOR03# INCLUDINGPHARMACOLOGICAL ENDOSCOPIC ANDSURGICALMODALITIES3INCE03#PATIENTSAREATAHIGHRISKOFDEVELOPING CHOLANGIOCELLULARCARCINOMAANDOTHERMALIGNANTTUMOURSMAINLYOFTHE') TRACT THEYSHOULDBEREGULARLYSCREENED)NMOSTCASES LIVERTRANSPLANTATION REMAINSTHEONLYTHERAPYTHATIMPROVESSURVIVALINTHESEPATIENTS )NPARTICULARINCHILDRENANOVERLAPSYNDROMEBETWEEN03#ANDAUTOIM MUNEHEPATITISISCOMMON"IOCHEMICALANDHISTOLOGICALCHARACTERISTICSOF BOTHDISEASESDETERMINEDIAGNOSISANDTHERAPEUTICAPPROACH

-ETABOLICLIVERDISEASE.ON ALCOHOLICSTEATOHEPATITIS.!3( .ON ALCOHOLIC STEATOHEPATITIS IS DEFINED AS A CONSTELLATION OF HISTOLOGICAL ABNORMALITIES IDENTIFIED ON LIVER BIOPSIES THAT ARE SIMILAR TO THOSE SEEN IN ALCOHOLIC LIVER DISEASE BUT THESE HISTOLOGICAL ABNORMALITIES ARE FOUND IN PATIENTSWHOCONSUMELITTLEOREVENNOALCOHOL4HEPREVALENCEOF.!3( HASINCREASEDOVERTHELASTYEARSINPARALLELWITHTHEINCREASINGPREVALENCE OF OBESITY AND TYPE  DIABETES 4HE MOST COMMON UNDERLYING FACTOR FOR .!3(ISTHEPRESENCEOFINSULINRESISTANCE;n=/BESITYANDASEDENTARY LIFESTYLE ARE THE TWO LARGEST RISK FACTORS FOR INSULIN RESISTANCE ;= .!3( ISMOSTCOMMONLYASYMPTOMATIC3OMEPATIENTSHAVESYMPTOMSLIKERIGHT UPPERABDOMINALPAIN FATIGUEANDMALAISE,IVERBIOPSYISTHEGOLDSTANDARD FORDIAGNOSIS.!3(ISTYPICALLYCHARACTERISEDBYSERUM!,4THATEXCEEDS THE!34BYUPTOTWO ORTHREE FOLD;= 4HEREISNOSTANDARDTREATMENTFOR.!3('ENERALRECOMMENDATIONS INCLUDEIMPROVINGMETABOLICRISKFACTORS4HEGOALISWEIGHTLOSS IMPROV INGINSULINSENSITIVITYANDTREATINGHYPERTRIGLYCERIDEMIA!NTIOXIDANTSAND URSODEOXYCHOLIC ACID HAVE ONLY LITTLE BENEFIT4HE COMPLICATIONS THAT CAN OCCUR IN .!3( ARE LIVER CIRRHOSIS ACUTE LIVER FAILURE AND HEPATOCELLULAR CARCINOMA!T PRESENT METFORMIN AND OTHER ANTIDIABETIC DRUGS ARE BEING EVALUATED

'ENETICLIVERDISEASES (AEMOCHROMATOSIS (AEMOCHROMATOSIS IS A MULTIORGAN DISEASE OF EXCESSIVE IRON DEPOSITION 4HE PRINCIPLE ORGANS AFFECTED INCLUDE LIVER HEART PANCREAS AND SKIN



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(AEMOCHROMATOSIS IS ONE OF THE MOST COMMON DISORDERS IN NORTHERN %UROPE4HEHIGHESTFREQUENCYOCCURSIN)RELANDANDINTHE"ASQUEREGION ;=4HEMAINBUTNOTTHEONLYGENEASSOCIATEDWITHHAEMOCHROMATOSISWAS LABELLED(&%;=4HE(&%GENEHASTWOCOMMONMUTATIONS #9AND ($!BOUT  OF TYPICAL HAEMOCHROMATOSIS PATIENTS IN MANY REGIONS OF THE WORLD ARE HOMOZYGOUS FOR THE #9 MUTATION OF THE (&% GENE $ISEASEMANIFESTATIONOCCURSTHROUGHINCREASEDINTESTINALIRONABSORPTION 4HEREISNOMECHANISMFORTHEINTESTINETOINCREASEIRONEXCRETIONTHISLEADS TOANETINCREASEINTHEIRONBALANCE RESULTINGINPROGRESSIVEACCUMULATION INMULTIPLEORGANS )N THE EARLY STAGES OF THE DISEASE PATIENTS USUALLY SHOW NO SYMPTOMS 7ITHPROGRESSOFIRONACCUMULATION ORGANDYSFUNCTIONSMAYRESULT)NTHE LATER STAGE OF THE DISEASE MANY SYMPTOMS OF HAEMOCHROMATOSIS ARE SEC ONDARYTOTHEUNDERLYINGLIVERDYSFUNCTION INCLUDINGSPIDERNAEVI PALMAR ERYTHEMA FATIGUE WEIGHT LOSS AND RIGHT UPPER ABDOMINAL PAIN4HE MOST COMMON NON LIVER RELATED SYMPTOMS OF HAEMOCHROMATOSIS ARE DIABETES CARDIACDISEASE ARTHROPATHY ENDOCRINEABNORMALITIESANDPIGMENTATIONOF THESKIN'LUCOSEINTOLERANCEHASBEENFOUNDINOFHAEMOCHROMATOSIS PATIENTS WITH LIVER CIRRHOSIS ;= )RON ACCUMULATION IN THE PANCREAS MAY RESULT IN PANCREATIC ENDOCRINE DYSFUNCTION AND THEREFORE IN ADULT ONSET DIABETESMELLITUS#ARDIACDISEASEINHAEMOCHROMATOSISINCLUDESBOTHCAR DIOMYOPATHY AND ARRHYTHMIAS %CHOCARDIOGRAPHY IS THE PREFERRED INITIAL DIAGNOSTICTESTANDABNORMALITIESCANBESEENINUPTOOFREFERREDCASES ;=4HE CHARACTERISTIC PIGMENTATION OF HAEMOCHROMATOSIS IS A BRONZE OR GREYCOLOUROFTHESKIN 4HE INITIAL LABORATORY TESTING INCLUDES SERUM IRON TOTAL IRON BINDING CAPACITYANDFERRITIN%LEVATEDTRANSFERRINGSATURATIONABOVEANDELE VATEDSERUMFERRITINARESUGGESTIVEOFIRONOVERLOAD'ENETICTESTINGOFTHE #9-UTATIONOFTENLEADSTOTHEEXACTDIAGNOSEOFHAEMOCHROMATOSIS (AEMOCHROMATOSISCANBETREATEDSUCCESSFULLYWITHPHLEBOTOMYTHERA PY4HEVENESECTIONOFnMLISEQUIVALENTTOAPPROXIMATELYn MGIRON-AINTENANCEVENESECTIONAFTERIRONDEPLETIONOFnVENESECTIONS PERYEARAREDONEINMOSTPATIENTS ALTHOUGHTHERATEOFIRONREACCUMULATION ISHIGHLYVARIABLE;=!REASONABLETARGETFORTHETRANSFERRINGSATURATIONIS BELOW

!LPHA ANTITRYPSINDEFICIENCY !LPHA ANTITRYPSINISPRODUCEDPRIMARILYBYHEPATOCYTES BUTALSOBYALVEO LAR MACROPHAGES AND INTESTINAL CELLS ;= 4HE DISEASE IS ASSOCIATED WITH PULMONARYEMPHYSEMA CHRONICLIVERDISEASEANDHEPATOCELLULARCARCINOMA ALTHOUGH ONLY ABOUT  OF HOMOZYGOTES DEVELOP A CLINICALLY SIGNIFICANT LIVERDISEASE4HEPATHOGENESISOFLIVERDISEASEINPATIENTSWITHALPHA ANTI

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TRYPSIN DEFICIENCY IS LESS CLEAR )T HAS BEEN SUGGESTED THAT CONFORMATIONAL CHANGES OF THE UNSTABLE ALPHA ANTITRYPSIN VARIANTS LEAD TO RETENTION OF POLYMERSOFABNORMALLYFOLDEDALPHA ANTITRYPSININTHEHEPATOCYTEENDO PLASMATICRETICULUM; =!LPHA ANTITRYPSINDEFICIENCYOFTENPRESENTSIN THENEONATALPERIODWITHJAUNDICE PALESTOOL DARKURINEANDELEVATEDLIVER ENZYMES (OWEVER THE LIVER DISEASE CAN REMAIN CLINICALLY SILENT FOR MANY YEARSALTHOUGHABNORMALBIOCHEMICALLIVERENZYMESANDSIGNSOFLIVERCIR RHOSISMAYAPPEAR 4HEREISNOSPECIFICTHERAPYFORALPHA ANTITRYPSINDEFICIENCY ASSOCIATED LIVERDISEASE4HEONLYTREATMENTOPTIONFORPATIENTSWITHPROGRESSIVELIVER DISEASEISALIVERTRANSPLANTATION!DDITIONALLYITISRECOMMENDEDTOAVOID OTHER RISK FACTORS SUCH AS PASSIVE AND ACTIVE SMOKING AND HEAVY DRINKING 3INCE THERE IS NO SPECIFIC TREATMENT OPTION THE GOAL HERE IS TO GIVE THESE PATIENTSTHESTANDARDMEDICALSUPPORTANDTOMANAGETHECOMPLICATIONSOF CHRONICLIVERDISEASE

7ILSONDISEASE 7ILSON DISEASE IS AN AUTOSOMAL RECESSIVE DISORDER THAT LEADS TO A COPPER OVERLOADINTHELIVERANDOTHERORGANS4HEUNDERLYINGGENEHASBEENIDEN TIFIEDANDMORETHANSINGLEPOINTMUTATIONSOFTHISGENEHAVEBEENIDEN TIFIED;=4HEREFORE UNLIKEINHAEMOCHROMATOSIS ASINGLEGENETICTESTIS NOTAVAILABLEONAROUTINEBASISFOR7ILSONDISEASE7ILSONDISEASEISFOUND WORLDWIDE BUTMOSTCOMMONLYINNORTHERN CENTRALANDEASTERN%UROPEAN COUNTRIES ; =4HE CLINICAL PRESENTATION CAN VARY7ILSON DISEASE MAY PRESENTASCHRONICORFULMINANTLIVERDISEASE ASAPROGRESSIVENEUROLOGICAL DISORDER WITHOUT EVIDENT HEPATIC DYSFUNCTION OR AS A RATHER NONDESCRIPT PSYCHIATRICILLNESSORACUTEEPISODESOFHAEMOLYSIS4HEHALLMARKOF7ILSON DISEASEISTHE+AYSER &LEISCHERRING WHICHISPRESENTEDINOFPATIENTS WITH NEUROLOGICAL SYMPTOMS AND SOMEWHAT OVER A HALF WITHOUT +AYSER &LEISCHER RINGS ARE NOT SPECIFIC FOR7ILSON DISEASE4HEY MAY BE FOUND IN PATIENTSWITHOTHERTYPESOFCHRONICLIVERDISEASE -EDICAL TREATMENT FOR 7ILSON DISEASE INVOLVES EITHER CHELATION OR INDUCTION OF METALLOTHIONINS 4HERE ARE TWO GENERALLY ACCEPTED ORAL CHELATING AGENTS PENICILLAMINE AND TRIENTINE :INC INTERFERES WITH COP PER ABSORPTION FIRSTLY BY COMPETING FOR A COMMON CARRIER ABSORPTION AND SECONDLY INDUCING METALLOTHIONIN IN ENTEROCYTES ALLOWING COPPER ABSORBED INTO THEM TO BE EXCRETED BY DESQUAMATION ;= 5NTREATED 7ILSONS DISEASE IS UNIVERSALLY FATAL WITH MOST PATIENTS DYING FROM LIVER DISEASEANDAMINORITYFROMPROGRESSIVENEUROLOGICDISEASE(OWEVER IN MOSTCASESLIVERTRANSPLANTATIONOFTENREMAINSTHEONLYEFFECTIVETHERAPY FOR PATIENTS WITH END STAGE LIVER DISEASE THE GENETIC DEFECT IS CURED BY LIVERTRANSPLANTATION



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!BSTRACT 4HEREISAVARIETYOFDIFFERENTIALDIAGNOSESOFACUTEANDCHRONICHUMANHEPATITISREGULARLY SEEN IN CLINICAL PRAXIS 2ISK FACTOR ASSESSMENT FOR SPECIFIC ENTITIES PROVIDES IMPORTANT INFORMATION AND SHOULD GUIDE INDIVIDUAL DIAGNOSTIC PROCEDURES ,IVER SCREENING TESTS OFTENREMAINTHEFIRSTINDICATORFORHEPATICPATHOLOGIESANDSHOULDINCLUDEQUANTIFICATION OF LIVER ENZYMES LIVER FUNCTION PARAMETERS AND CHOLESTATIC PARAMETERS .EVERTHELESS VIRUSSEROLOGYSHOULDALWAYSBEDONEDURINGFURTHERLABORATORYEVALUATION4OESTIMATE THE PARENCHYMAL LIVER DAMAGE AND TO EXCLUDE BILIARY OBSTRUCTION OR HEPATIC LESIONS AN ABDOMINAL ULTRASOUND SCAN IS ESSENTIAL! LIVER BIOPSY MAY COMPLETE THE DIAGNOSTIC APPROACH IF EITHER THE UNDERLYING HEPATIC PATHOLOGY REMAINS OBSCURE OR PARENCHYMAL LIVERDAMAGENEEDSTOBEDEFINED

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0TS PATIENTSY YEARSM MALEW FEMALE"-) BODYMASSINDEX!.! ANTINUCLEARANTIBODY !-! ANTI MITOCHONDRIALANTIBODYP!.#! ANTI PERINUCLEARNEUTROPHILECYTOPLASMATICANTI BODY3-! SMOOTHMUSCLEANTIBODY,+- LIVERKIDNEYMICROSOMALANTIBODY,+- SOLUBLE LIVERANTIGENANTIBODY

NEPHROPATHY OR 2AYNAUD 3YNDROME 3PECIFICALLY MEMBRANOUS GLOMERU LONEPHRITIS AND PANARTERITIS NODOSA OFTEN INVOLVING SPLANCHNIC ARTERIES ARE HIGHLYSUGGESTIVEFORHEPATITIS")NCONTRAST HEPATITIS#ISCLEARLYLINKEDTO MIXEDESSENTIALCRYOGLOBULINEMIAWHICHMAYALSOCAUSE2AYNAUD 3YNDROME RENAL IMPAIRMENT AND ARTHROPATHY 4HE ASSOCIATION OF CHRONIC HEPATITIS # WITH LYMPHOPROLIFERATIVE DISEASES HAS NOT BEEN DEFINED AS WELL BUT SHOULD BECONSIDERED;=-OREOVER VIRALHEPATITISCOULDPROVOKEOTHERMANIFES TATIONS INCLUDINGNEURITIS MYELITIS 'UILLAIN "ARRÏSYNDROME;= 3JOGRENS SYNDROME;= CARDIOMYOPATHY;=ANDLICHENPLANUS;=

$IFFERENTIATIONOFOTHERCAUSESOFLIVERDAMAGE $ESPITEVIRALHEPATITISBEINGONEOFTHELEADINGCAUSESOFHUMANHEPATITIS WORLDWIDE OTHER HEPATIC PATHOLOGIES SHOULD BE IDENTIFIED BY CLINICAL HIS TORY$IFFERENTIALDIAGNOSISRANGESFROMCOMMONTOXICORISCHAEMICEVENTS HEREDITARY ENTITIES TO AUTOIMMUNE DISEASES WHICH MANIFEST AS ACUTE OR CHRONICLIVERDISEASE0RIORTOACCURATEDIAGNOSISOFASPECIFICHEPATICPATHOL OGY OTHERDEFINEDDISEASEENTITIESMUSTFIRSTBEEXCLUDED

.ON ALCOHOLICSTEATOHEPATITIS 0ARTICULARLYHEPATICSTEATOSISANDORNON ALCOHOLICSTEATOHEPATITIS.!3( HAVE BECOME AN INCREASING MEDICAL BURDEN IN INDUSTRIALISED COUNTRIES



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REQUIRINGDIAGNOSTICATTENTION$EPENDINGONTHEANALYSEDCOHORTBETWEEN  AND  OF THE GENERAL POPULATION ARE AFFECTED BY HEPATIC STEATOSIS ;=(ENCE POPULATION BASEDSURVEYSHAVEALSOSTATEDTHATHEPATICSTEATOSIS OR.!3(MIGHTBERESPONSIBLEFORnOFPATIENTSWITHELEVATEDLIVER ENZYMES; =4HISGROUPOFPATIENTSISCHARACTERISEDBYRISKFACTORSWHICH COULD BE IDENTIFIED BY CLINICAL HISTORY 3PECIFICALLY OBESE PATIENTS "-) KGM HAVEAHIGHPREVALENCE OFSTEATOSISHEPATITISCOMPARED TONON OBESEINDIVIDUALS"-)KGM WHOSHOWAPREVALENCEOFONLY  ;= %NLARGED WAIST CIRCUMFERENCE ETHNIC BACKGROUND AND DIABETES MELLITUS ARE FURTHER RISK FACTORS OF HEPATIC STEATOSIS ;= $IFFERENT STUDIES SUGGESTTHATPATIENTSWITHSTEATOSISMAYDEVELOP.!3(INnOREVEN END UP WITH CIRRHOSIS IN n OF ALL CASES ;= $IFFERENTIATION FROM VIRAL HEPATITIS IS HAMPERED BY THE FACT THAT CHRONIC VIRAL INFLAMMATION INDUCES HEPATICSTEATOSISANDTHATSTEATOSISPROMOTESDISEASEPROGRESSIONOFCHRONIC VIRALHEPATITIS

4OXICHEPATITIS 4OXICHEPATITISISAFURTHERIMPORTANTDIFFERENTIALDIAGNOSIS WHICHISOFTEN LINKED TO CHRONIC ALCOHOL CONSUMPTION OR HEPATOTOXIC MEDICATION 4HE OVERALLPREVALENCEOFALCOHOL RELATEDLIVERDISEASEISHIGHERINMALEPATIENTS ANDINCREASESWITHAGE!LCOHOLICLIVERDISEASESHOULDBESTRONGLYSUSPECTED IN PATIENTS WITH AN ALCOHOL CONSUMPTION MORE THAN n GDAY WHICH EQUALS A DAILY INDULGENCE OF ABOUT  L BEER  L WINE OR  ML DISTILLED SPIRITS;=3PECIFICDRINKINGHABITS LIKEALCOHOLCONSUMPTIONOUTSIDEMEAL TIMES SHOULDALSOBERECOGNISEDASRISKFACTORSFORALCOHOLICLIVERDISEASE ;= #OMPARED TO MEN WHO SHOW A HIGHER PREVALENCE OF ALCOHOLIC LIVER DISEASE FEMALE INDIVIDUALS CONSUMING ALCOHOL ON A REGULAR BASIS ARE AT HIGHERRISKOFDEVELOPINGALCOHOL RELATEDLIVERDISEASE;=#LEARAETIOLOGI CALDIFFERENTIATIONOFLIVERDAMAGEDURINGCHRONICALCOHOLCONSUMPTIONIS HINDEREDBYARELEVANTPROPORTIONOFPATIENTSWITHADDITIONALVIRALHEPATITIS ANDOR OBESITY ;=4O IDENTIFY OTHER CAUSES OF TOXIC HEPATITIS CLINICAL HIS TORY SHOULD FOCUS ON MEDICATIONS WHICH WERE STARTED WITHIN n MONTHS PRIORTOONSETOFLIVERDAMAGE.EWMEDICATIONSAREOFTENRESPONSIBLEFOR HEPATOTOXICITY%VENMEDICATIONSWHICHWEREADMINISTEREDFORMORETHAN MONTHSHAVEBEENIDENTIFIEDASCAUSATIVEHEPATOTOXICAGENTS)NWESTERN COUNTRIES ACETAMINOPHEN IS THE NUMBER ONE CAUSE OF ACUTE LIVER FAILURE LEADINGTOLIVERTRANSPLANTATION!SLIFE THREATENINGAMOUNTSOFHEPATOTOXIC AGENTS ARE REGULARLY INGESTED DURING SUICIDAL ATTEMPTS ANAMNESIS SHOULD ALSOFOCUSONLIFECRISISANDDEPRESSIVESYMPTOMS&URTHERMORE DRUGSLIKE AMPHETAMINESANDCOCAINEHAVEBEENASSOCIATEDWITHACUTELIVERDAMAGE AND SHOULD BE SCREENED )N %UROPE ACCIDENTAL INGESTION OF FUNGAL TOXIN DEATH CAP MUSHROOM !MANITA PHALLOIDES HAS TO BE CONSIDERED DURING ASSESSMENTOFLIVERFAILURE

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)SCHAEMICHEPATITIS ! FURTHER FOCUS SHOULD BE SET ON ISCHAEMIC HEPATITIS CAUSED BY SEVERE HYPOTENSION LIVER CONGESTION AND THROMBO EMBOLIC EVENTS !S ISCHAEMIC HEPATITIS USUALLY AFFECTS CRITICALLY ILL PATIENTS CLINICAL HISTORY SHOULD RECOG NISE CHRONIC HEART FAILURE MYOCARDIAL INFARCTION ARRHYTHMIAS EXTENSIVE TRAUMA AND SEPSIS ;= #HRONIC HEPATIC CONGESTION DUE TO CARDIAC INSUF FICIENCYMIGHTEVENCAUSEFIBROTICREMODELLINGANDEND STAGELIVERDISEASE ;=&INALLY LIVER SPECIFICVASCULARPATHOLOGIESOFTHELIVERLIKE"UDD #HIARI SYNDROME AND VENO OCCLUSIVE DISEASE CONTRIBUTE TO ACUTE AND CHRONIC HEPATICDAMAGEASWELL; =)SCHAEMICHEPATITISUSUALLYDOESNOTPRESENT WITHPROLONGEDSUB CLINICALPERIODSANDMIMICSTHECLINICALPICTUREOFACUTE HEPATITIS4HE INTERVAL BETWEEN THE INITIAL ISCHAEMIC EVENT AND THE CLINICAL MANIFESTATIONOFHEPATICDAMAGEONLYTAKESHOURS$EPENDINGONTHEEXTENT OF ISCHAEMIC LIVER DAMAGE LIVER FAILURE AND ITS COMPLICATIONS MAY ENSUE 4HE SYMPTOMS OF ACUTE LIVER DAMAGE ARE ESSENTIALLY THE SAME AS FOR VIRAL HEPATITIS STATED BEFORE THOUGH EXTRAHEPATIC MANIFESTATIONS RESEMBLE THE UNDERLYINGPATHOLOGY

(EREDITARYLIVERDISEASE (EREDITARYLIVERDISEASESMAYALSOPRESENTWITHHEPATITISTYPELIVERDAMAGE (AEMOCHROMATOSISISTHEMOSTCOMMONHEREDITARYDISEASEOFTHECAUCASIAN POPULATION (AEMOCHROMATOSIS SHOULD BE SUSPECTED IF MALE PATIENTS USU ALLYOLDERTHANYEARS PRESENTWITHSIGNSOFLIVERDAMAGE)RONOVERLOAD ALSOAFFECTSTHEENDOCRINEPANCREASANDDIABETESMELLITUSMIGHTBEASSOCI ATEDWITHHAEMOCHROMATOSIS&URTHERINDICATORSFORHAEMOCHROMATOSISARE ATYPICAL CARDIAC DISEASE UNEXPLAINED ARTHROPATHY OR MALE SEXUAL DYSFUNC TION&ORFIRSTDEGREERELATIVESOFPATIENTSSUFFERINGFROMHAEMOCHROMATOSIS FURTHERDIAGNOSTICWORKUPISALSORECOMMENDED;=7ILSONSDISEASEMAY MIMICDIVERSEHEPATICENTITIES RANGINGFROMACUTEHEPATICFAILURETOCIRRHO SIS!LTHOUGHITISARAREENTITY 7ILSONSDISEASESHOULDTHEREFOREBEINCLUDED INDIFFERENTIALDIAGNOSISOFACUTEANDCHRONICHEPATITIS0ARTICULARLYPATIENTS BETWEEN  AND  YEARS OF AGE SHOULD BE SCREENED FOR 7ILSONS DISEASE 0ATIENTSHIGHLYSUSPICIOUSFOR7ILSONSDISEASEARETHOSEWITHNEUROLOGICAL FINDINGSINADDITIONTOHEPATICPATHOLOGY4HESPECTRUMOFNEUROLOGICALSIGNS INCLUDESTREMOR ATAXIAANDSEIZURES0SYCHIATRICSYMPTOMSINCLUDINGDEPRES SION NEUROSIS OR EVEN FRANK PSYCHOSIS HAVE BEEN OBSERVED &INALLY OTHER ORGANSYSTEMSINCLUDINGTHEHEARTANDKIDNEYMIGHTBEAFFECTEDBY7ILSONS DISEASE ;=!LPHA  ANTITRYPSIN !4 DEFICIENCY WHICH AFFECTS ABOUT  IN nNEWBORNS SHOULDALSOBEINCLUDEDINDIFFERENTIALDIAGNOSIS4HE CLINICAL PICTURE OF !4 DEFICIENCY IS USUALLY RESTRICTED TO SIGNS OF HEPATIC ANDPULMONARYDISEASE(EPATICMANIFESTATIONSMIGHTRANGEFROMELEVATED LIVERENZYMESANDORJAUNDICETOLIVERCIRRHOSIS!STHELIFETIMERISKOFLIVER



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CIRRHOSISISABOUTnINPATIENTSSHOWING!4DEFICIENCY PATIENTSWITH UNEXPLAINED LIVER DAMAGE SHOULD UNDERGO DIAGNOSTIC SCREENING FOR THIS ENTITY;=

!UTOIMMUNEDISEASE !UTOIMMUNE HEPATITIS !)( IS THE PREDOMINANT AUTOIMMUNE DISEASE AFFECTINGTHELIVER)N%UROPE!)(SHOWSANINCIDENCEOFIN PER SONS PER YEAR ;=!)( SHOWS A BIPOLAR INCIDENCE DURING LIFETIME WITH A JUVENILEANDANADULTPEAK2ECENTOBSERVATIONSSUGGESTTHAT!)(MAYALSO BE COMMON IN THE ELDERLY POPULATION!)( MAY PRESENT AS ACUTE HEPATIC DETERIORATION OR AS CHRONIC LIVER DAMAGE AND CIRRHOSIS !N INCONSISTENT COURSEWITHHEPATICFLARE UPSANDPERIODSOFREMISSIONISREGULARLYOBSERVED DURING!)(4HEDIAGNOSISOF!)(ISBASEDONADEFINEDCLINICALANDSERO LOGICAL SCORING SYSTEM THAT REQUIRES THE STRICT EXCLUSION OF OTHER HEPATIC PATHOLOGIES SUCHASVIRAL TOXICORCHOLESTATICLIVERDISEASE;=0ARTICULARLY !)( SHOULD BE EXCLUDED IN EVERY PATIENT WHO ALSO PRESENTS WITH OTHER AUTOIMMUNEDISEASES!S!)(ISASSOCIATEDWITHGENETICFACTORS LIKE(,! $2 AND $2 A POSITIVE FAMILY HISTORY MIGHT LEAD TO!)( ;= #HRONIC AUTOIMMUNE PATHOLOGIES AFFECTING THE BILE DUCTS LIKE PRIMARY BILIARY CIR RHOSIS0"# ANDPRIMARYSCLEROSINGCHOLANGITIS03# ALSOMIMICCHRONIC HUMAN HEPATITIS AND REGULARLY LEAD TO LIVER CIRRHOSIS AND END STAGE LIVER DISEASE7HEREAS0"#ISCHARACTERISEDBYAGRADUALPROGRESSOFCHOLESTATIC MANIFESTATIONS AND LIVER DAMAGE 03# IS OFTEN COMPLICATED BY RECURRING CHOLESTATICEPISODES$ETERIORATIONOFCHOLESTATICSYMPTOMSDURING03#ARE USUALLY CAUSED BY RECURRENT CHOLANGITIS4HEY MAY FOLLOW BILIARY INTERVEN TIONS OR ARE BASED ON OBSTRUCTION BY DE NOVO CHOLANGIOCARCINOMA 03# USUALLY AFFECTS MALE PATIENTS AND MANIFESTS ITSELF BETWEEN THE TH AND TH DECADE OF LIFE!BOUT  OF ALL 03# PATIENTS ALSO SUFFER FROM INFLAMMA TORY BOWEL DISEASE PREDOMINANTLY ULCERATIVE COLITIS ;= 0"# PRIMARILY AFFECTS WOMEN AND USUALLY DOES NOT MANIFEST IN PATIENTS YOUNGER THAN  YEARS"EFORELIVERDAMAGEHASCAUSEDVISUALSIGNOFJAUNDICEANDCIRRHOSIS PATIENTS OFTEN REPORT ABOUT CHRONIC PRURITUS &URTHERMORE AUTOIMMUNE DISEASELIKE3JOGRENSSYNDROMEAND3CLERODERMIAAREASSOCIATEDWITH0"# "ESIDEDISTINCT03# 0"#AND!)(OVERLAPSYNDROMESBETWEENTHESETHREE PATHOLOGIESAREPOSSIBLE;=

#HOLESTASISANDPATHOLOGIESOFBILIRUBINHOMEOSTASIS "ESIDE PARENCHYMAL LIVER DAMAGE CHOLESTATIC DISEASES HAVE TO BE CONSID EREDINTHEDIFFERENTIALDIAGNOSISOFHUMANHEPATITIS-ECHANICBILIARYTRACT OBSTRUCTIONBYGALLSTONESANDMALIGNANCIESARETHEMOSTCOMMONPATHOLO GIESAFFECTINGTHEBILIARYTREE"OTHAREASSOCIATEDWITHTYPICALPRESENTATION

$IFFERENTIALDIAGNOSISOFHUMANHEPATITIS



EXAMINATIONFINDINGSANDCLINICALHISTORYMIGHTALREADYALLOWFORDIFFEREN TIATION4HUS MALIGNANCIES SHOULD BE STRONGLY CONSIDERED IN PATIENTS COM PLAININGABOUTANOREXIA LOSSOFAPPETITE NIGHTSWEATSANDFEVER)NCONTRAST GALLSTONES USUALLY PRESENT WITH POSTPRANDIAL COLIC PAIN OF THE RIGHT UPPER ABDOMEN0ARTICULARLYFEMALE FERTILEANDOBESEPATIENTSAREATHIGHERRISK TODEVELOPGALLSTONES )FBILEDUCTOBSTRUCTIONHASBEENEXCLUDED HAEMOLYSISSHOULDBEINCLUD EDINTODIAGNOSTICWORKUP3EVERALHEREDITARY INFECTIOUSANDHAEMATOLOGIC ENTITIESAREPOSSIBLECAUSESANDLABORATORYTESTINGFORHAEMOLYSISSHOULDBE INCLUDEDASANINITIALSTEPTOWARDSDIFFERENTIALDIAGNOSE-ILDHYPERBILIRUBI NAEMIARESULTINGFROMHEREDITARYDEFICIENCYOFBILIRUBINMETABOLISMSHOULD COMPLETEDIFFERENTIATIONOFJAUNDICE

"ACTERIALANDPARASITICHEPATITIS 3EVERALBACTERIALORPARASITICINFECTIONSAFFECTTHELIVEREITHERDUETODIRECT HEPATIC INVOLVEMENT OR DUE TO EFFECTS OF SYSTEMIC INFLAMMATION "ACTERIAL LIVERABSCESSUSEDTOBEAFREQUENTINFECTIOUSCOMPLICATIONBUTTHEINCIDENCE HAS DECLINED SINCE POTENT ANTIBIOTICS HAVE BEEN AVAILABLE "ACTERIAL LIVER ABSCESSES ARE USUALLY POLYMICROBIAL INCLUDING AEROBIC 'RAM NEGATIVE OR 'RAM POSITIVESPECIESASWELLASANAEROBICBACTERIA;=4HEBACTERIAREACH THELIVEREITHERBYTHEBILIARYORTHEHAEMATOLOGICALROUTE!SACONSEQUENCE THEBILIARYANDSPLANCHNICSYSTEMSHOULDBEINTENSIVELYSCREENEDFORBACTE RIAL FOCI!MEBIC ABSCESSES ARE PARTICULARLY OBSERVED IN PATIENTS ORIGINAT ING FROM ENDEMIC AREAS OR WITH POSITIVE TRAVEL ANAMNESIS #LINICAL HISTORY DIFFERENTIATES PRECEDING BLOODY DIARRHOEA WHICH CHARACTERISE AMEBIASIS IN ONLY  OF ALL CASES ;= "ESIDE COMMON COMMENSAL BACTERIA MANY OTHER BACTERIAL PATHOGENS INCLUDING TYPHOID FEVER AND BRUCELLOSIS MIGHT CAUSEHEPATICDETERIORATION,EPTOSPIROSIS AVERYCOMMONZOONOSIS HASTO BECONSIDEREDIFACUTEFLU LIKESYMPTOMSAREACCOMPANIEDBYHAEMOLYTIC JAUNDICEANDRENALIMPAIRMENT!LSOSECONDARYSYPHILISSHOWSLIVERINVOLVE MENT WITH HEPATITIS IN UP TO  OF ALL CASES "ESIDE NON SPECIFIC GENERAL SYMPTOMS LYMPHADENOPATHYANDCHARACTERISTICMACULOPAPULARRASHOFTHE PALMANDSOLESMAYBEOBSERVED &OR PATIENTS WITH A POSITIVE TRAVEL HISTORY SCHISTOSOMIASIS AND MALARIA AREIMPORTANTDIFFERENTIALDIAGNOSISOFHUMANHEPATITIS0ARTICULARLYSCHIS TOSOMIASIS CONTRIBUTES TO A LARGE NUMBER OF PATIENTS WITH LIVER FIBROSIS WORLDWIDEANDHASTOBECONSIDEREDINPATIENTSORIGINATINGFROMENDEMIC AREAS IN %ASTERN!SIA AND .ORTHERN!FRICA!S RECURRENT SCHISTOSOMIASIS MAYAGGRAVATEPROGRESSIONOFCHRONICVIRALHEPATITIS BOTHENTITIESREQUIRE DIAGNOSTICATTENTIONANDTREATMENT0ARTICULARLYIN%GYPTWHEREEFFORTSTO ERADICATESCHISTOSOMIASISWITHINTRAVENOUSMEDICATIONSHAVECONTRIBUTEDTO AHIGH(#6PREVALENCEBYCONTAMINATEDSYRINGES CO INFECTIONSWITHBOTH ENTITIES HAVE BECOME A SERIOUS MEDICAL BURDEN ;= -ALARIA TRANSIENTLY



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AFFECTS THE LIVER THROUGHOUT ITS LIFECYCLE AND CAUSES HAEMOLYTIC JAUNDICE DURING ERYTHROCYTIC STAGES .EVERTHELESS HEPATOCYTE DAMAGE IS OBSERVED PREDOMINANTLY DURING 0LASMODIUM FALCIPARUM INFECTIONS AND PARTICULARLY INPATIENTSWITHUNDERLYINGVIRALHEPATITISACUTELIVERFAILUREHASBEENDOCU MENTED;=

$IAGNOSTICTESTS ,IVERENZYMES )NUPTOOFALLCASES ACUTEHEPATITISDOESNOTPRESENTWITHCLINICALSYMP TOMS SOLABORATORYFINDINGSAREOFTENTHEONLYINDICATORSFORHEPATITISAND HELPTODIFFERENTIATETHECAUSESOFLIVERDAMAGE!POPULATION BASEDSURVEY IN %UROPE FOR EXAMPLE HAS IDENTIFIED ELEVATED LIVER ENZYMES DEFINED AS  TIMES THE UPPER REFERENCE LIMIT 52, IN UP TO  OF THE GENERAL POPULATION %LEVATION OF ALANINE AMINOTRANSFERASE !,4 ANDOR ASPARTATE AMINO TRANSFERASE!34 TENTIMESBEYONDTHE52,ARERELIABLEMARKERSTODIS CRIMINATEACUTEHEPATICDAMAGEFROMUNSPECIFICORCHRONICCAUSESOF!,4 AND!34ELEVATIONS#UTOFFVALUESTOIDENTIFYACUTEHEPATICINJURYARE 5LFOR!34SENSITIVITY SPECIFICITY AND5LFOR!,4SENSI TIVITY SPECIFICITY  ;= ! PROPORTION OF UP TO  OF MILD LIVER ENZYME ELEVATIONS  X 52, WEREASSOCIATEDWITHVIRALHEPATITISININDUSTRIALISEDCOUNTRIESANDTHE NUMBERS ARE DECLINING DUE TO VACCINATION AND SCREENING EFFORTS %LEVATED !,4=52, OCCURSINOF(#6 POSITIVEINDIVIDUALSANDIN DURING("6INFECTION;=)NCONTRAST ONLYABOUTOFPRONOUNCED!34 ELEVATIONS5LARECAUSEDBYVIRALHEPATITISINTHEPATIENTSATTENDING CLINIC;=+INETICSOF!34AND!,4ELEVATIONSDURINGACUTEVIRALHEPATITIS ARE CHARACTERISED BY A GRADUAL SLOPE WHICH REACHES ITS MAXIMUM AFTER A VARIABLEPERIODOFTHREEORMOREWEEKSFROMONSETOFFIRSTENZYMEELEVATION $URINGFURTHERTIME COURSETHE!34AND!,4LEVELSDECLINEGRADUALLY!34 !,42ATIOAREREGULARLYOBSERVEDDURINGVIRALHEPATITISINABOUT OF THE INFECTED PATIENTS ;=4HOUGH VIRAL HEPATITIS IS NOT THE MAIN CAUSE WHICH IS RESPONSIBLE FOR SEVERE LIVER DAMAGE LABORATORY FINDINGS OCCUR IN OTHERSETTINGS )NASIGNIFICANTPROPORTIONOFPATIENTS WITHINCIDENTALLYDIAGNOSED !34 ELEVATIONS  5L IT WAS ATTRIBUTED TO ISCHAEMIC HEPATIC EVENTS 0ARTICULARLYDURINGVERYHIGH!34AND!,4ELEVATIONS 5LISCHAEMIC HEPATITIS SHOULD BE CONSIDERED4HIS LABORATORY FINDINGS FURTHER LIMITS THE SPECTRUMOFPOTENTIALDIFFERENTIALDIAGNOSISTOISCHAEMIC TOXICORACUTEVIRAL HEPATITIS;=#LINICALOBSERVATIONSOFISCHAEMICHEPATITISHAVESHOWNTHAT THEMEDIANPEAK!,4LEVELREACHES 5LDURINGCONGESTIVEHEARTFAILURE AND 5LDURINGHYPOXEMIA;=!TTIMEOFCLINICALADMISSIONPATIENTS

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AFASTDECLINEOFLIVERENZYMESISTYPICALLYOBSERVEDDURINGISCHAEMICLIVER DAMAGE )SCHAEMIC HEPATITIS IS ALSO CHARACTERISED BY A LACTATE DEHYDROGE NASE ,$( ELEVATION WHICH REACHES MEDIAN PEAK LEVEL   5L ;= 4HEMEAN!,4,$(RATIOISSIGNIFICANTLYLOWERDURINGISCHAEMICHEPATITIS COMPAREDTOVIRALHEPATITISANDA!,4,$(RATIOISUSEFULTODIFFEREN TIATEISCHAEMICHEPATITISFROMVIRALHEPATITISWITHASENSITIVITYOFANDA SPECIFICITYOF;= 4OXICHEPATITISSHARESSEVERALLABORATORYFEATURESOFISCHAEMICHEPATITIS "ESIDE FAST KINETICS AND HIGH PEAK LEVELS OF LIVER ENZYME ALTERATIONS THE !,4,$(RATIOUSUALLYDOESNOTEXCEEDACUT OFFVALUEOF;=$ESPITE THEDIFFERENTCHARACTERISTICSOFTOXICHEPATITISTHEDIAGNOSISISOFTENMISSED 4HELEADINGFACTORTOWARDSTHERIGHTDIAGNOSISISACAREFULHISTORYOFTOXIN ORDRUGEXPOSITION5NCOMPLICATEDALCOHOLICHEPATITISISTHEMOSTCOMMON TOXICHEPATITISANDUSUALLYPRESENTSWITHMILDLABORATORYALTERATIONS$URING UNCOMPLICATED ALCOHOLIC HEPATITIS AMINOTRANSFERASES OFTEN DO NOT EXCEED TIMESTHEUPPERREFERENCELIMIT)THASBEENSHOWNTHAT!34!,4RATIO  IS REASONABLY SPECIFIC TO IDENTIFY ALCOHOLIC HEPATITIS FROM OTHER CAUSES OFACUTELIVERDAMAGEANDTHEMAJORITYOFPATIENTSn WITHALCOHOLIC HEPATITISSHOWAN!34!,4RATIO;= )N THE GENERAL POPULATION PRESENTING WITH !34 ELEVATIONS  5L ALMOSTOFALLCASESWERECONTRIBUTEDTOCHOLESTATICDISEASE;=,IVER ENZYME ELEVATION DURING MECHANICAL BILIARY OBSTRUCTION EXCEEDS   5LINn#HARACTERISTICALLYTHEELEVATEDLIVERENZYMESRESOLVEWITHINA WEEKDESPITEPERSISTINGCHOLESTASIS;=3ERUMALKALINEPHOSPHATASE!0 DERIVEDFROMTHECHOLANGIALEPITHELIALISANIMPORTANTLABORATORYINDICATOR FORCHOLESTASIS-ILD!0ELEVATIONSBELOWTHREETIMESTHEREFERENCELIMITARE CONSIDERED NON SPECIFIC AND MAY OCCUR DURING OTHER HEPATIC PATHOLOGIES )N CONTRAST STRIKING!0 ELEVATIONS STRONGLY SUGGEST BILE DUCT OBSTRUCTION IF EXTRAHEPATIC SKELETAL SOURCES OF!0 HAVE BEEN EXCLUDED 'AMMA GLU TAMYL TRANSPEPTIDASE''4 ISCONSIDEREDTOBEMORESPECIFICFORHEPATIC PATHOLOGIES BECAUSENORELEVANTQUANTITIESOF''4AREFOUNDINBONETIS SUE!S''4ISMAINLYLOCATEDINTHEMICROSOMALCELLULARCOMPARTMENTIT MAYBEINDUCEDBYALCOHOLANDTOXICDRUGS)F''4INDUCTIONISSUSPECTED THE!0''4 RATIO  OFFERS A HELPFUL PARAMETER TO IDENTIFY CHOLESTATIC DISEASE $URING CHRONIC HEPATITIS ELEVATION OF LIVER ENZYMES SHOWS VARI ABLE PROFILES AND IS EVEN MISSING IN A RELEVANT PROPORTION OF PATIENTS 4HEREFORE THEDIAGNOSTICVALUETODIFFERENTIATETHECAUSESOFCHRONICLIVER DAMAGEORCHRONICHEPATITISISRELATIVELYLOW.EVERTHELESS THE!34!,4 RATIOHELPSTOIDENTIFYLIVERCIRRHOSISINPATIENTSWITHCHRONICLIVERDISEASE OFDIFFERENTAETIOLOGYIFALCOHOLICLIVERDISEASEHASBEENEXCLUDED;n= !S MENTIONED BEFORE COMBINATIONS OF LABORATORY PARAMETERS LIKE!34 !,4 AND !,4,$( RATIO OR ADDITIONAL TESTING OF CHOLESTATIC PARAM ETERSMIGHTHELPTOINCREASEDISCRIMINATORYPOWEROFLIVERTESTSREGARDING CHRONICENTITIES

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PERIODS AFTER INFECTION4HEREFORE DETECTION OF (!6 )G- IS CONSIDERED AS ROUTINETESTTOIDENTIFYACUTE(!6INFECTIONAND(!6)G'RESEMBLESPAST EXPOSUREANDIMMUNITYAGAINST(!6;= %NZYMEIMMUNOABSORBENTASSAYS%)! ARESTANDARDDIAGNOSTICTESTSTO IDENTIFYACUTEORCHRONICHEPATITIS"VIRUSINFECTION4HESTANDARDSCREENING TESTSAREABLETOIDENTIFY("6INFECTIONASEARLYASnWEEKSPRIORTOTHE ONSETOFSYMPTOMSOFACUTEHEPATITIS"4HERECOMMENDEDSTANDARDSCREEN ING TEST FOR ("6 IS BASED ON THE DETECTION OF HEPATITIS " SURFACE ANTIGEN ("S!G AND HEPATITIS " CORE ANTIGEN ("C!G SPECIFIC ANTIBODIES )N A SMALL PROPORTION OF PATIENTS ("S!G TARGETED ASSAYS FAIL TO DETECT ("6 INFECTION4HESEFALSENEGATIVE("S!GTESTSRESULTFROM("S!GTITRESBELOW THEDETECTIONLIMITDURINGCHRONIC("6INFECTIONANDFROM("S!GESCAPE MUTATIONS WHICH ARE NOT DETECTED BY ANTIBODIES EMPLOYED FOR ROUTINE SCREENING4ESTSAGAINST("E!GAND("6NUCLEICACIDSARERECOMMENDED COMPLEMENTARY TESTS TO IDENTIFY ACTIVE ("6 REPLICATION )N CONTRAST NEU TRALISINGANTI ("S!GANTIBODIES)5ML INDICATEANELIMINATED("6 INFECTION OR IMMUNISATION AGAINST ("6 ;= )N PATIENTS WITH POSITIVE ("S!G TITRES AND A HIGH RISK OF ($6 INFECTION ASSAYS OF TOTAL ANTI ($6 ANTIBODIES ARE CONSIDERED AS SUFFICIENT TEST TO IDENTIFY HEPATITIS $ CO OR SUPER INFECTION &IRSTGENERATION%)!STODETECTANTI (#6SPECIFICIMMUNGLOBULINSHAVE BEEN INTRODUCED BY  AS SCREENING FOR (#6 INFECTION ;= .OWADAYS THIRDGENERATION%)!SAREIMPLEMENTEDINCLINICALPRACTICE WHICHDETECTA PANELOFSPECIFICIMMUNGLOBULINSAGAINSTEPITOPESOFDIFFERENTSTRUCTURALAND NON STRUCTURAL(#6PROTEINS4HESETHIRDGENERATION%)!SSHOWASPECIFIC ITYOFABOUTANDHAVEREDUCEDTHEDIAGNOSTICWINDOWAFTER(#6INFEC TIONTOABOUTWEEKS;=0ATIENTSWITH(#6INFECTIONHAVEDETECTABLE ANTIBODIESINnATCLINICALPRESENTATION BUTAFTERTHREEMONTHSABOUT WILLHAVEDEVELOPEDDETECTABLEANTIBODYTITRES;=)G-ANTIBODIESARE NO RELIABLE MARKERS TO DISCRIMINATE ACUTE FROM CHRONIC (#6 INFECTION AS nOFCHRONICALLY(#6INFECTEDPATIENTSSTILLSHOWPOSITIVEANTI (#6 )G-TITRES; =0ATIENTSWITHSIGNSANDSYMPTOMSOFACUTEHEPATITISAND NEGATIVE(#6SEROLOGYSHOULDUNDERGO(#6NUCLEICACIDTESTS(#60#2 ASSAYSSHOWAHIGHSENSITIVITYANDAREABLETODETECTAMINIMAL(#62.! THRESHOLD OF n )5ML IN THE SERUM4HE HIGH SENSITIVITY DETECTS ACTIVE (#6 REPLICATION ALREADY n WEEKS AFTER (#6 INFECTION 1UANTITATIVE (#6 2.! TESTS AND (#6 GENOTYPING ARE COMPLEMENTARY TESTS DESIGNED TO IDENTIFY PROGNOSIS OF (#6 INFECTION AND TO MONITOR RESPONSE TO (#6 THERAPY;= !UTOIMMUNE MEDIATED LIVER DAMAGE IS ASSOCIATED WITH DIFFERENT TYPES OFAUTO ANTIBODIES)NDICATORSOF!)(AREELEVATEDANTIBODYTITRESDIRECTED AGAINST LIVERKIDNEY MICROSOMES ,+- SOLUBLE LIVER ANTIGEN 3,! AND LIVER PANCREAS ANTIGENS !N ELEVATION OF TOTAL SERUM GAMMAGLOBULIN IS ALSO INDICATIVE FOR!)(!)( IS ALSO ASSOCIATED WITH HIGH TITRES  OF ANTI NUCLEARANTIBODY!.! ANDORANTI SMOOTHMUSCLEANTIBODY3-! 

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OBSTRUCTION EG ABOUT  ;= &URTHER IMPROVEMENT OF BILIARY IMAGING HASBEENPROPOSEDBYMAGNETICRESONANCECHOLANGIOGRAPHYBUTISNOTYET AVAILABLEFORROUTINEUSE5PTONOW ENDOSCOPICRETROGRADECHOLANGIOSCOPY %2# IS THE MOST SENSITIVE DIAGNOSTIC TOOL TO IDENTIFY BILIARY PATHOLOGIES AND SHOULD BE CONSIDERED IF BILIARY OBSTRUCTION IS SUSPECTED FOR CLINICAL REASONS%2#ALSODETECTSMINIMALBILEDUCTIRREGULARITIESANDTHEREFOREIS CONSIDEREDTHEGOLDENSTANDARDFORDIAGNOSISOF03#ANDOFFERSTREATMENT OPTIONSFORDOMINANTSTRICTURESORBILIARYCONCREMENTS;= "ESIDEULTRASOUNDWHICHISAVALUABLETOOLTOSCREENANDMONITORFOCAL HEPATICLESIONS CONTRASTENHANCEDCOMPUTEDTOMOGRAPHY#4 ISTHESTAN DARDPROCEDURETOCONFIRMHEPATICMETASTASISOR(##%SPECIALLYINCONTEXT OFLIVERCIRRHOSISEARLYARTERIALPHASEENHANCEMENTOF(##NODULESALLOWS DETECTIONOF(###OMPAREDTOULTRASOUND WHICHREACHESASENSITIVITYOF ENHANCED#4SHOWSASENSITIVITYOFORMOREFORTHEDETECTIONOF (##4HEREFORE#4ISSTANDARDFORTHEBASELINEASSESSMENTANDMONITORING OFCIRRHOTICLIVERSINCONTEXTOF(##TREATMENT; =#ONTRASTENHANCED ULTRASOUNDAPPEARSTOBEAVERYPROMISINGALTERNATIVEANDMIGHTBEEQUIVA LENTFORTHEDIAGNOSISOF(##ANDOTHERFOCALHEPATICLESIONS

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MULTINUCLEATED HEPATOCYTES AND BROAD AREAS OF PARENCHYMAL COLLAPSE ARE TYPICALLY OBSERVED IN!)(7HEREAS BILE DUCT DAMAGE OR LOSS AND HEPATIC STEATOSIS ARE UNCOMMON DURING!)( ;= 0RIMARY BILIARY CIRRHOSIS 0"# ISCHARACTERISEDBYACHRONICNON SUPPURATIVEDESTRUCTIVECHOLANGITISOFTHE SMALLBILEDUCTS'RANULOMAFORMATION PROGRESSIVELOSSOFBILEDUCTSANDCEL LULARINFILTRATESWITHANNON HOMOGENICDISTRIBUTIONTHROUGHOUTTHELIVERARE TYPICALFINDINGS;=(ISTOLOGYOF03#MAYALSOSHOWBILEDUCTDESTRUCTION SIGNSOFCHOLANGITISANDCHOLESTASIS.EVERTHELESS APRECISECHOLANGIOGRAPHIC ASSESSMENTISTHEMOSTIMPORTANTDIAGNOSTICTOOL AS03#USUALLYAFFECTSTHE MEDIANANDLARGEBILEDUCTS; =!LSOGRANULOMATOUSHEPATITISISACOM MONHISTOLOGICALFINDING WHICHISFOUNDINnOFLIVERSPECIMENS"ESIDE 0"#MENTIONEDABOVE THECAUSESOFGRANULOMATOUSHEPATITISINCLUDEAUTO IMMUNOLOGICAL INFECTIOUS AND TOXIC ENTITIES 3ARCOIDOSIS AND TUBERCULOSIS REMAIN THE MOST IMPORTANT DIFFERENTIAL DIAGNOSIS AND ARE RESPONSIBLE FOR nOFALLCASESWITHGRANULOMATOUSHEPATITIS&URTHERMORE THEDIFFER ENTIALDIAGNOSISOFGRANULOMATOUSHEPATITISSHOULDBEEXTENDEDINPATIENTS WITHACQUIREDIMMUNODEFICIENCYSYNDROMETOATYPICALMYCOBACTERIA HISTO PLASMOSIS AND CRYPTOCOCCOSIS )F NO SPECIFIC PATHOLOGY COULD BE IDENTIFIED TOXICMEDICATIONSSHOULDBECONSIDEREDASALTERNATIVECAUSE

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#OMPARATIVEPATHOLOGY 4HOMAS,ONGERICHAND0ETER3CHIRMACHER )NSTITUTEOF0ATHOLOGY 5NIVERSITYOF(EIDELBERG )M.EUENHEIMER&ELD (EIDELBERG 'ERMANY

!BSTRACT (EPATITIS IS DEFINED AS A NECROINFLAMMATION OF THE LIVER DISPLAYING LIVER CELL DAMAGE INFLAMMATORYCELLINFILTRATES ANDREGENERATIONTOAVARIABLEEXTENT)NCONTRASTTOACUTE HEPATITIS WHICH IS CHARACTERISED BY A SELF LIMITING DAMAGE OF THE ACINAR PARENCHYMA CHRONICHEPATITISISPATHOMORPHOLOGICALLYDEFINEDBYTHEPERSISTENCEOFNECROINFLAMMA TION PORTALPREDOMINANCEOFMONONUCLEARINFLAMMATORYINFILTRATES ANDTHEDEVELOPMENT OF FIBROSIS 7HEREAS (!6 AND (%6 DO NOT CAUSE CHRONIC HEPATITIS IN HUMANS ("6 ALONE OR IN COMBINATION WITH ($6 AND (#6 INFECTION MAY RESULT IN CHRONIC LIVER DISEASEINHUMANS WHICHMAYPROGRESSTOLIVERCIRRHOSISAND(##)NITIALANIMALMODELS FORTHESTUDYOFVIRALHEPATITISBELONGEDTOTHEGROUPOFNONHUMANPRIMATES ESPECIALLY CHIMPANZEES WHICH CAN BE INFECTED BY HUMAN HEPATITIS VIRUSES4HESE MODELS DEVELOP A MILDER ACUTE HEPATITIS COMPARED TO HUMANS AND ALTHOUGH CHRONIC HEPATITIS MAY ALSO DEVELOP PROGRESSIVELIVERDISEASEANDLIVERCIRRHOSISAREGENERALLYABSENT)NTHECASEOF ("6 SEVERALMAMMALIANANDAVIAN("6 RELATEDVIRUSESAREKNOWN4HEMOSTINTENSIVE LYCHARACTERISEDMODELISTHE%ASTERNWOODCHUCKINFECTEDWITH7(64HISEXAMPLEISTHE ONLYMODELINWHICHCHRONICLIVERDISEASEAND(##FREQUENTLYDEVELOP2ECENTLY THETREE SHREW4UPAIABELANGERI HASBECOMEANINTERESTINGMODELSINCEITCANBEINFECTEDWITH HUMANHEPATITISVIRUSES ITCANBEHANDLEDMOREEASILYCOMPAREDTOCHIMPANZEES ANDIT CANBEUSEDINTRANSPLANTATIONMODELS!DDITIONALLY SEVERALTRANSGENICMICEANDHUMAN MOUSE CHIMERA HAVE BEEN DEVELOPED WHICH ALLOW FOR THE STUDYING OF VIRAL REPLICATION ANDNOVELTHERAPEUTICAPPROACHESINVIVO

)NTRODUCTION #OMPARATIVE PATHOLOGY OF HEPATITIS MAY ADDRESS SEVERAL TOPICS THE DIF FERENCES BETWEEN ACUTE AND CHRONIC HEPATITIS DIFFERENCES IN HISTOLOGICAL FEATURES DUE TO CAUSATIVE AGENTS AS WELL AS TYPICAL AND ATYPICAL FORMS OF HEPATITIS EG FOLLOWING LIVER TRANSPLANTATION  !DDITIONALLY THE FEATURES OF HEPATITIS CAN BE COMPARED BETWEEN DIFFERENT SPECIES EG HUMANS AND RODENTS&INALLY CERTAINAREASWITHINHUMANHEPATITISCANBESTUDIEDINANI MALMODELS



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

(EPATITISREPRESENTSANECROINFLAMMATIONOFTHELIVER WHICHISHISTOLOGI CALLYCHARACTERISEDBYAVARIABLEEXTENTOFLIVERCELLDAMAGE INFLAMMATORY CELL INFILTRATES AND REGENERATION )N CONTRAST TO ACUTE HEPATITIS WHICH IS CHARACTERISED BY A PREDOMINANCE OF DAMAGE IN THE ACINAR PARENCHYMA CHRONIC HEPATITIS IS PATHOMORPHOLOGICALLY DEFINED BY THE PERSISTENCE OF NECROINFLAMMATION THEPREDOMINANCEOFPORTALMONONUCLEARINFLAMMATORY INFILTRATES ANDVARIABLENECROINFLAMMATORYACTIVITYATTHEPORTAL PARENCHY MALINTERFACE ASWELLASTHEDEVELOPMENTOFFIBROSIS

4HEMORPHOLOGICALPATTERNOFHEPATITIS !CUTEHEPATITIS 'ENERALASPECTS 4HESEVERITYOFACUTEHEPATITISMAYVARYFROMASYMPTOMATICTOFULMINANT HEPATICFAILURE!CCORDINGLY THEHISTOLOGICALCHANGESSEENINACUTEHEPATITIS MAYVARY-ILDACUTEHEPATITISTYPICALLYSHOWSAVARIABLEPICTUREINCLUDING HEPATOCELLULARSWELLING SINGLECELLNECROSIS APOPTOSISACIDOPHILICBODIES CHOLESTASISCANALICULARANDHEPATOCELLULAR ACINARINFLAMMATION +UPFFER CELLACTIVATIONPROMINENCE CEROIDPHAGOCYTOSIS ANDLIVERCELLREGENERA TION4HE COMBINATION OF HEPATOCELLULAR CELL DEATH @DROP OUT AND SMALL REGENERATINGHEPATOCYTESMAYLEADTOADISARRAYOFLIVERCELLPLATES WHICHIS ANIMPORTANTDIAGNOSTICCRITERIONOFACUTEHEPATITIS/FNOTE AMILDPORTAL INFLAMMATIONMOSTLYLYMPHOPLASMACYTIC SOMETIMESEVENINCLUDINGSOME MILD BILE DUCT DAMAGE MAY BE A MINOR COMPONENT OF ACUTE HEPATITIS )N CONTRAST TO CHRONIC HEPATITIS PORTAL INFLAMMATION DOES NOT PREDOMINATE ANDTHEOUTLINEOFTHEPORTALTRACTREMAINSWELLDEFINEDTOWARDSTHEACINAR PARENCHYMA)NMORESEVEREDISEASE THEREMAYBECONFLUENTNECROSES FRE QUENTLY PRONOUNCED AROUND PERIVENULAR AREAS OR EVEN BRIDGING NECROSES CONNECTINGCENTRAL PORTALORCENTRAL CENTRALAREAS#ONSEQUENTLY ACOLLAPSE OF THE RETICULIN FIBRE FRAMEWORK MAY BE SEEN IN APPROPRIATE STAINS EG MODIFIED 'OMORIS WHICH MAY BE REPLACED BY FIBROUS SCARRING AFTER THE HEPATITISHASRESOLVED)NCASEOFEXTENSIVECONFLUENTNECROSES ADUCTULAR REACTION WHICH CONSISTS OF DUCTULAR PROLIFERATIONS ASSOCIATED FIBROSIS AND NEUTROPHILIC INFILTRATION OCCURS AT THE PORTAL INTERFACE 4HIS FEATURE MAY MIMICEXTRA ACINARCHOLESTASISEG BILEDUCTOBSTRUCTION ANDHASTHUSTO BEDIFFERENTIATED)NCASEOFFULMINANTACUTEHEPATITIS PANACINARANDMUL TIACINARNECROSISAREOBSERVED WHICHAREASSOCIATEDWITHAPPROXIMATIONOF INDIVIDUALPORTALTRACTS LARGECOLLAPTICAREASANDEXTENSIVEFUTILEDUCTULAR REACTION !CUTE HEPATITIS MAY BE CAUSED BY VIRAL INFECTION EG HEPATOTROPIC VIRUSES BUTALSO%PSTEIN "ARRVIRUS%"6 CYTOMEGALOVIRUS#-6 (ERPES SIMPLEXVIRUS(36 6ARICELLAZOSTERVIRUS6:6 ADENOVIRUS ENTEROVIRUS

#OMPARATIVEPATHOLOGY



ETC DRUGS TOXINS ALCOHOLEXPOSURE BACTERIALINFECTIONASWELLASAUTOIM MUNITY AND7ILSONSDISEASE 3INCETHEREAREONLYAFEWPATHOGNOMONICFEATURESTHATALLOWAPRECISE HISTOLOGICALLYBASEDDEFINITIONOFTHEETIOLOGY ITISRATHERTHECHALLENGEFOR THECLINICIANTHANFORTHEPATHOLOGISTTODETERMINETHEUNDERLYINGETIOLOGY .EVERTHELESS ASPECIFICANDSOMETIMESOVERLAPPINGPATTERNMAYPOINTTOTHE UNDERLYINGETIOLOGY

3PECIFICFEATURESINACUTEHEPATITIS 4HEHISTOLOGICALSPECTRUMBYWHICHTHELIVERMAYREACTTOCERTAINAGENTSOR DAMAGEISLIMITED.EVERTHELESS ANEVALUATIONOFTHEMORPHOLOGICALINJURY PATTERN INCLUDING THE RECOGNITION OF SUBTLE FEATURES EG ACIDOPHILIC BOD IES EOSINOPHILS MAY ALLOW FOR THE IDENTIFICATION OF THE CAUSATIVE AGENT !DDITIONALLY IMMUNOHISTOLOGICALANDMOLECULARPATHOLOGICALANALYSESMAY ALLOWDIAGNOSISINASUBSETOFCASES4HEMOSTIMPORTANTDIAGNOSTICPATTERNS INCLUDE VIRUS TYPE HEPATITIS STEATOHEPATITIS ZONAL RESTRICTED PARENCHYMAL DAMAGE MONONUCLEOSIS LIKE HEPATITIS GRANULOMATOUS HEPATITIS AND FOCAL NECROTISINGHEPATITIS 6IRUS TYPEHEPATITIS 4HE TYPICAL LESION IN ACUTE VIRUS HEPATITIS CONSISTS OF SPOTTY CYTOLYTIC NECROSIS RESULTING IN A @DROP OUT OF INDIVIDUAL HEPATOCYTES WITHIN THE HEPATOCELLULAR PLATES AND APOPTOSIS RESULTING IN ACIDOPHILIC BODIES &IG ! 4HEREMNANTSOFTHESECELLSAREEITHERREMOVEDBYBLOODFLOWORTHEY ARE PHAGOCYTOSED LEADING TO CEROID LADEN MACROPHAGES AND PROMINENCE OF+UPFFERCELLS )N HEPATITIS ! VIRUS (!6 AND HEPATITIS % VIRUS (%6 INFECTION THERE MAY BE TWO COMMON SOMETIMES OVERLAPPING PICTURES POINTING TO THE CAUSATIVE AGENT ONE INCLUDES A PERIPORTAL ACCENTUATED INFLAMMATORY PATTERN RICHINPLASMACELLS WITHNOORLITTLEPERIVENULARNECROSIS; =4HE SECONDFEATUREISSO CALLEDCHOLESTATICHEPATITISWITHPROMINENTPERIVENULAR CHOLESTASIS AND ONLY MINIMAL INFLAMMATORY INFILTRATION 2ARELY (!6 MAY PRESENTASACUTEHEPATICFAILURE;= 3TEATOHEPATITIS 3TEATOHEPATITIS REPRESENTS THE PROGRESSIVE FORM OF FATTY LIVER DISEASE AND ISDEFINEDBYTHREEHISTOLOGICALFEATURESSTEATOSIS BALLOONINGANDNECROIN FLAMMATORYLESIONS; =4HEHISTOLOGICALCHANGESAREUSUALLYPRONOUNCED INTHEPERIVENULARREGION%VENTUALLYLIPOGRANULOMAS -ALLORY $ENKBODIES ANDGLYCOGENATEDNUCLEIMAYBESEEN3TEATOHEPATITISISUSUALLYCAUSEDBY CHRONICALCOHOLABUSEORNON ALCOHOLICCONDITIONSINCLUDINGADIPOSITAS TYPE ))DIABETESMELLITUS METABOLICSYNDROMEANDDRUGSEG AMIODARON NIFE DIPINE STEROIDS 



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

&IGURE  (EPATITIS PATTERN ! 6IRAL TYPE HEPATITIS PATTERN SHOWING FOCAL CYTOLYTIC LIVER CELL NECROSISANDACIDOPHILICBODIES" :ONALPATTERN4HEREISPERIVENULARNECROSISWITHLEUCOCYTIC DEMARCATIONANDHAEMORRHAGEINTHISCASEOFDRUG INDUCEDHEPATITIS# (EPATICSARCOIDOSIS WITHEPITHELIOIDCELLGRANULOMAWITHMULTINUCLEATEDGIANTCELLS$ %"6 HEPATITISWITHSINGLE FILEROWINGOFLEUCOCYTESSHOWINGSOMENUCLEARATYPIA

:ONALPATTERN 4HE ZONAL PATTERN SHOWS NECROSIS RESTRICTED TO A CERTAIN AREA OF THE LIVER ACINUS INPARTICULAROFTHEACINARZONE ASSEENINISCHAEMICLIVERCELLDAM AGE&IG" 4HISPATTERNMAYSOMETIMESBEOBSERVEDINSEVEREACUTEVIRAL HEPATITIS BUT PARTICULARLY WHEN ASSOCIATED WITH PROMINENT EOSINOPHILIC OR NEUTROPHILICINFILTRATION CHOLESTASTIS ORPERIBILIARYBASOPHILIAMAYPOINTTO DRUG AND TOXIN INDUCED LIVER DISEASE EG PHENPROCOUMON ;= .OTABLY DRUG OR TOXIN INDUCED HEPATITIS WHICH CAN PRODUCE ALL FORMS OF ACUTE CHRONIC VASCULARANDNEOPLASTICLIVERDISEASES HASTOBECONSIDEREDGENER ALLYINHEPATITISOFUNCERTAINETIOLOGY;= -ONONUCLEOSIS LIKEHEPATITIS 4HEMONONUCLEOSIS LIKEPATTERNSHOWSONLYMILDORABSENTLIVERCELLDAM AGEANDPROMINENTLYMPHOCYTESARESEENWITHINTHEHEPATICSINUSOIDS TYPI CALLYWITHSINGLEFILE LIKEROWING ANDPORTALTRACTS&IG$ 4HISPATTERNIS TYPICALFORACUTELIVERINVOLVEMENTIN%"6INFECTION)NSOMECASESOFACUTE HEPATITIS#VIRUS(#6 INFECTION THEREMAYBEAPROMINENTINTRASINUSOI

#OMPARATIVEPATHOLOGY



DAL LYMPHOCYTE AGGREGATION WITHOUT SEVERE LIVER CELL DAMAGE REMINISCENT OF %"6 HEPATITIS ;=!N ADDITIONAL DIFFERENTIAL DIAGNOSIS FOR THIS PATTERN INCLUDES MALIGNANT LYMPHOMA EG HEPATOSPLENIC 4 CELL LYMPHOMA ;= )MMUNOHISTOLOGICALANDMOLECULARPATHOLOGICALANALYSESDETECTIONOFVIRAL NUCLEIDACIDS CLONALITYOF4 CELLRECEPTORREARRANGEMENT MAYALLOWDIFFER ENTIATIONINMOSTCASES 'RANULOMATOUSPATTERN (EPATIC GRANULOMAS CONSIST OF HISTIOCYTIC EVEN EPITHELIOID CELLS A VARIED NUMBER OF MONONUCLEAR CELLS AND SOMETIMES MULTINUCLEATED GIANT CELLS (ISTOLOGICALLYCASEATINGEG TUBERCULOSIS GRANULOMAS NON CASEATINGGRAN ULOMAS LIPOGRANULOMAS ANDFIBRINRINGGRANULOMASCANBEDIFFERENTIATED)N MOSTCASES HEPATICGRANULOMASDEVELOPINRESPONSETOINFECTIONSESPECIALLY BACTERIALORPARASITIC DRUGHYPERSENSITIVITYEG ACETYLSALICYLICACID AMOXI CILLIN ORSYSTEMICDISEASESEG SARCOIDOSIS &IG# (ISTOCHEMICALSTAINS LIKE0!3 'RAM 'IEMSA 'ROCKOTT 7ARTHIN 3TARRY OR(ALEMAYBEHELPFUL FORDETERMININGTHECAUSEOFAGIVENGRANULOMA #ASEATING GRANULOMAS IN CONTRAST TO NON CASEATING GRANULOMAS SHOW A CENTRALNECROSISSURROUNDEDBYEPITHELIOIDCELLS MULTINUCLEATEDGIANTCELLS ANDHISTIOCYTES4HEYARETYPICALLYSEENINTUBERCULOSIS&IG$ .ON CASE ATING GRANULOMAS IN PORTAL TRACTS NEAR DAMAGED BILE DUCTS ARE ALMOST CER TAINLYDUETOPRIMARYBILIARYCIRRHOSIS,IPOGRANULOMASAREFREQUENTLYSEEN INSTEATOHEPATITISANDCONSISTOFAFATVACUOLESURROUNDEDBYLYMPHOCYTES /CCASIONALLY FIBRINRINGGRANULOMASCOMPOSEDOFAFATVACUOLESURROUNDED BYARINGOFFIBRIN EPITHELIOIDCELLS GIANTCELLSANDNEUTROPHILSMAYBESEEN 4HEY MAY BE OBSERVED IN INFECTIOUS DISEASES EG 1 FEVER SYSTEMIC DIS EASES (ODGKINS DISEASE SYSTEMIC LUPUS ERYTHEMATODES OR DRUG INDUCED LIVERDAMAGEALLOPURINOL ;n= &OCALNECROTISINGPATTERN 4HEFOCALNECROTISINGPATTERNOFACUTEHEPATITISSHOWSNON ZONALRESTRICTED GROUP OR BRIDGING NECROSIS WITH HAEMORRHAGE WHICH MAY BE DEMARCATED BY POLYMORPHIC NEUTROPHILS4HIS TYPE OF ACUTE HEPATITIS IS MAINLY SEEN IN ATYPICAL FORMS OF HEPATITIS INCLUDING (36 &IG ! 6:6 ADENOVIRUS &IG " ENTEROVIRUS ETC AND MOST FREQUENTLY OCCURS IN THE SETTING OF IMMUNOSUPPRESSION !TYPICAL HEPATITIS DIFFERS FROM CLASSICAL HEPATITIS IN THATITFREQUENTLYALLOWSDIAGNOSISDUETOADDITIONALTYPICALMORPHOLOGICAL FEATURES!DENOVIRAL INFECTION WHICH RARELY OCCURS IN LIVER ALLOGRAFTS MAY MIMIC#-6HEPATITISMICROABSCESSFORMATION &IG# INITSINITIALSTAGES BUT MAY PROCEED TO CONFLUENT HAEMORRHAGIC NECROSES RESULTING IN USUALLY FATALINFECTION;="ESIDEHAEMORRHAGICNECROSES THEPRESENCEOF@SMUDGE CELLSISADIAGNOSTICFEATUREINADENOVIRALHEPATITIS!NOTHERFREQUENTLYFATAL VIRALINFECTIONISACUTENECROTISING(ERPESSIMPLEXOR6ARIZELLAZOSTERHEPA TITIS WHICHSHOWCHARACTERISTICEOSINOPHILICORBASOPHILICNUCLEARINCLUSIONS #OWDRYBODIES INVIABLEHEPATOCYTESADJACENTTONECROSES;=



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

&IGURE  !TYPICAL HEPATITIS ! &OCAL NECROTISING (ERPES SIMPLEX HEPATITIS .OTE THE EOSI NOPHILICCOWDRY TYPENUCLEARINCLUSIONSINTHEVITALHEPATOCYTESADJACENTTOTHENECROSISINSERT (36 IMMUNOHISTOCHEMISTRY  " &OCAL NECROTISING ADENOVIRUS HEPATITIS WITH NUMEROUS SMUDGECELLSINSERT # -ICROABSCESSFORMATIONIN#-6 HEPATITISINSERT#-6 IMMUNOHIS TOCHEMISTRY $ (EPATICTUBERCULOSISSHOWINGCASEATINGNECROSISSURROUNDEDBYEPITHELIOID GRANULOMAWITHLANGHANSTYPEMULTINUCLEATEDGIANTCELL

#HRONICHEPATITIS 'ENERALASPECTS )NADULTS CHRONICHEPATITISISPRIMARILYGROUPEDACCORDINGTOTHEUNDERLYING ETIOLOGY;=4HUS INFECTIONS DRUGSTOXINS AUTOIMMUNITY METABOLIC INHER ITEDDISEASESANDNON DEFINED@CRYPTOGENICMECHANISMSAREDIFFERENTIATED #LASSICAL INFECTIOUS AGENTS CAUSING CHRONIC HEPATITIS INCLUDE HEPATITIS " VIRUS ("6 INFECTION ALONE OR IN COMBINATION WITH HEPATITIS $ VIRUS ($6 AND (#6 INFECTION )NFREQUENTLY %"6 INFECTION MAY INDUCE CHRONICHEPATITIS;=7HETHERAFEWBACTERIASUCHASTHE(ELICOBACTERSPE CIESMAYCAUSECHRONICHEPATITISORACCELERATEDISEASEPROGRESSIONISRATHER QUESTIONABLE ;= "ESIDE PURE AUTOIMMUNE HEPATITIS SO CALLED AUTOIM MUNEOVERLAPSYNDROMESWITHPRIMARYBILIARYCIRRHOSIS0"# ANDPRIMARY SCLEROSING CHOLANGITIS 03# ARE DIAGNOSED VERY INFREQUENTLY 4HE LIST OF MEDICATIONSWHICHMAYINDUCECHRONICHEPATITISISSTILLGROWINGDUETOTHE INCREASING NUMBER OF APPROVED DRUGS #LASSICAL AGENTS INCLUDE ANTIBIOTICS

#OMPARATIVEPATHOLOGY



EG NITROFURANTOINE ANDANTIEPILEPTICSEG PHENYTOIN )MPORTANTLY EVEN HERBS SUCH AS THE #HINESE MEDICINAL HERB *IN "U (UAN HAVE BEEN IDENTI FIEDTOINDUCECHRONICHEPATITIS-ETABOLICDISEASESMOSTLYDONOTBELONGTO THE CLASSICAL ETIOLOGICAL SPECTRUM OF CHRONIC HEPATITIS ALTHOUGH ESPECIALLY 7ILSONSDISEASEMAYSHOWHEPATITICFEATURES

0ATHOMORPHOLOGYANDSPECIALFEATURESOFCHRONICHEPATITIS "YDEFINITION CHRONICHEPATITISSHOWSAPREDOMINANCEOFPORTALINFLAMMA TION )NTERFACE HEPATITIS IN OLDER TERMINOLOGY PIECEMEAL NECROSIS ACINAR INFLAMMATION ANDPORTALORSEPTALFIBROSISAREFACULTATIVEFEATURES$ISEASE PROGRESSIONISDRIVENBYTHEEXTENTOFINTERFACEHEPATITISANDISMORPHOLOGI CALLYCHARACTERISEDBYCYTOPLASMICDEGENERATIONANDAPOPTOSISOFPERIPORTAL HEPATOCYTES IN CLOSE CONTACT WITH INFILTRATING LYMPHOCYTES 4HE FEATURES OF CYTOPLASMIC DEGENERATION INCLUDE HEPATOCELLULAR BALLOONING GRANULAR AGGREGATIONOFCELLORGANELLESANDPARTIALDISSOLUTIONOFNUCLEARANDCELLULAR MEMBRANES;= 4HE MORPHOLOGY BASED DEFINITION OF THE UNDERLYING ETIOLOGY IS NOT POSSIBLE IN MOST CASES AND IT REQUIRES THE CLINICAL PATHOLOGICAL CONTEXT TO PREVENT NON ESSENTIAL ADDITIONAL DIAGNOSTIC PROCEDURES 4HUS CLINICAL AND SEROLOGICALINFORMATIONAREIMPORTANTFORTHEASSESSMENTOFALIVERBIOPSY SPECIMEN.EVERTHELESS THEREARESEVERALCHARACTERISTICFEATURESINDICATING THECAUSATIVEAGENT)NCASEOF("6 THESEINCLUDEGROUND GLASSHEPATOCYTES &IG ! OR SO CALLED @SANDED NUCLEI FREQUENTLY IN IMMUNOSUPPRESSED PATIENTS  'ROUND GLASS HEPATOCYTES ARE THE MORPHOLOGICAL CORRELATE OF ("S ANTIGEN OVERLOAD OF THE ENDOPLASMIC RETICULUM @3ANDED NUCLEI ARE CHARACTERISEDBYEOSINOPHILIC HOMOGENOUS FINE GRAINEDNUCLEARINCLUSIONS GIVINGTHEIMPRESSIONOFSAND LIKEGRANULATION4HEYARELESSFREQUENTLYSEEN COMPAREDTOGROUND GLASSHEPATOCYTESANDARECAUSEDBYNUCLEAR("CANTI GENOVERLOAD;="ESIDECHRONIC("6INFECTION THEYAREOBSERVEDMORE FREQUENTLY IN THE CASE OF AN ("6 ($6 COINFECTION )N THESE CASES THEY AREIMMUNOHISTOLOGICALLYPOSITIVEFORTHEDELTAANTIGEN;='ENERALLY THE LIVERHISTOLOGYIN("6 ($6COINFECTIONSHOWSMORESEVEREINFLAMMATORY ACTIVITY COMPARED TO ("6 MONOINFECTION #YTOPLASMIC OR MEMBRANOUS ("C ANTIGEN STAINING AS WELL AS MEMBRANOUS ("S ANTIGEN STAINING HAVE DIAGNOSTICIMPORTANCESINCETHEYMARKVIRALREPLICATINGCELLS;=-OLECULAR BIOLOGICALAPPROACHESFOR0#2 BASEDDETECTIONOFVIRALNUCLEICACIDSHAVE BEENESTABLISHED BUTTHEYAREONLYUSEDINSELECTEDCASESINWHICHDIAGNOSIS ISDIFFICULTEG UNCLEARMORPHOLOGY  (#6 INFECTION IS GENERALLY MILDER AND MORE FREQUENTLY SHOWS PERI PORTAL MACROVESICULAR STEATOSIS SINUSOIDAL INFLAMMATORY AGGREGATES WITH PRONOUNCED +UPFFER CELL ACTIVATION AND PORTAL LYMPH FOLLICLE FORMATION &IG" COMPAREDTO("6;=%SPECIALLYTHEFORMATIONOFPORTALLYMPH FOLLICLESISCONSIDEREDTYPICALFOR(#6INFECTION ALTHOUGHITISNOTPATHOG



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

&IGURE3PECIALFEATURESOFCHRONICHEPATITIS! #HRONICHEPATITIS"WITHNUMEROUSGROUND GLASS HEPATOCYTES " 0ORTAL LYMPHOID FOLLICLE IN (#6 INFECTION # !UTOIMMUNE HEPATITIS WITHMARKEDINTERFACEHEPATITIS NUMEROUSPLASMACELLS ANDPSEUDOGLANDFORMATION$ $RUG INDUCED HEPATITIS WITH SPARSE PORTAL MONONUCLEAR INFLAMMATORY INFILTRATES AND INTERMINGLED EOSINOPHILS

NOMONIC IN ANY CASE )MMUNOHISTOLOGICAL DETECTION OF (#6 PROTEINS IS POSSIBLE ON SNAP FROZEN TISSUE BUT RESULTS OBTAINED FROM FORMALIN FIXED PARAFFIN EMBEDDEDTISSUEAREUNRELIABLEINMOSTCASES; = (ISTOLOGICAL CHARACTERISTICS OF UNTREATED AUTOIMMUNE HEPATITIS &IG # ARE SEVERE INFLAMMATORY ACTIVITY AND ALMOST ALWAYS INCLUDE THE FEATURES OF CHRONICITY AT TIME OF DIAGNOSIS4HERE IS TYPICALLY SEVERE INTERFACE HEPATITIS ROSETTEFORMATIONOFPERIPORTALHEPATOCYTES PLASMACELL RICHPORTALINFLAMMA TORYINFILTRATES AND BYDEFINITION NOORONLYMINIMALBILEDUCTDAMAGE;=

)NFLAMMATORYACTIVITYANDFIBROSISINCHRONICVIRALHEPATITIS 4HE DEGREE OF INFLAMMATION AND HEPATOCELLULAR DAMAGE NECROINFLAMMA TION MAYVARYCONSIDERABLYINTERINDIVIDUALLYASWELLASDURINGTHECOURSE OF A CHRONIC HEPATITIS IN A GIVEN PATIENT 4HUS THE INFLAMMATORY ACTIVITY SEEN IN A LIVER BIOPSY SPECIMEN GRADING ONLY REFLECTS A SNAPSHOT OF THE DISEASE PROCESS ;= .EVERTHELESS INFLAMMATORY ACTIVITY ESPECIALLY THE

#OMPARATIVEPATHOLOGY



&IGURE'RADINGOFCHRONICHEPATITIS! -INIMALCHRONICHEPATITISGRADE SHOWINGMODER ATEPORTALINFLAMMATIONANDANINTACTLIMITINGPLATE" -ILDCHRONICHEPATITISGRADE ADDI TIONALLYSHOWINGFOCALPIECEMEALNECROSISANDSOMEACINARSINGLECELLNECROSIS# #ONFLUENT INTERFACE HEPATITIS AND NUMEROUS PARENCHYMAL CYTOLYTIC NECROSIS IN THIS CASE OF MODERATE CHRONICHEPATITISGRADE $ 3EVERECHRONICHEPATITISGRADE WITHMARKEDINTERFACEHEPA TITISANDHEPATOCELLULARGROUPNECROSISTOP 

DEGREE OF INTERFACE HEPATITIS HAS A HIGH PREDICTIVE VALUE WITH RESPECT TO DISEASE PROGRESSION ;= $URING THE LAST DECADES SEVERAL ATTEMPTS HAVE BEENMADETOASSESSINFLAMMATORYACTIVITYMOREOBJECTIVELYBYINTRODUCING GRADINGSYSTEMSTHATSCORETHEVARIOUSPARAMETERSOFINFLAMMATORYACTIVITY 3EVERALSCORINGSYSTEMSHAVEBEENBROADLYACCEPTED BUTUNTILNOW NOSINGLE WORLDWIDE CONSENSUS FOR THE USE OF A CERTAIN SYSTEM HAS BEEN ACHIEVED 3YSTEMSPROPOSEDINCLUDETHESCORESACCORDINGTO$ESMETETAL;= "ATTS AND,UDWIG;= )SHAKSMODIFIEDHISTOLOGICALACTIVITYINDEXM(!) ;= ORIGINATINGFROM+NODELLSSCORE;= ANDTHE-%4!6)2SCOREFORASSESS MENTOFCHRONIC(#6INFECTION;=$ESMETSSCORE4AB ISDESCRIPTIVEIN TERMSOFINFLAMMATORYACTIVITYANDDISTINGUISHESFOURGRADESMINIMAL MILD MODERATE SEVEREGRADETO &IG!n$ 4HISGRADINGSYSTEMHASSEVERAL ADVANTAGESCOMPAREDTOOTHERSCORESITHASAGOODINTER ANDINTRAOBSERVER REPRODUCIBILITY; =ITALSOHASABROADAPPLICABILITYAND IMPORTANTLY IT HASAGOODCORRELATIONTOTHEMORECOMPLEXM(!)SCORE4AB  4HE DEGREE OF FIBROSIS AND TISSUE REMODELLING ARCHITECTURAL DISTOR TION STAGING IS THE MOST IMPORTANT INTEGRATIVE MEASURE FOR PROGRESSION



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

4ABLE'RADINGOFCHRONICVIRALHEPATITISACCORDINGTO$ESMET3CHEUER;= GRADE

VERBAL

M(!) 3CORE HISTOLOGICALFEATURES



MINIMAL

n

MILDPORTALINFLAMMATION NONEORMINIMALACINAR INFLAMMATIONFEWSINGLECELLNECROSIS NOINTERFACE HEPATITIS



MILD

n

MILDTOMODERATEPORTALINFLAMMATION FOCALINTERFACE HEPATITIS SOMESINGLECELLNECROSIS NOCONFLUENTNECROSIS



MODERATE

n

MODERATETOSEVEREPORTALINFLAMMATION CONFLUENT INTERFACEHEPATITIS MULTIPLESINGLECELLNECROSIS SOME CONFLUENTNECROSIS NOBRIDGINGORPANACINARNECROSIS



SEVERE

n

SEVEREPORTALINFLAMMATIONANDINTERFACEHEPATITIS SEVEREACINARINFLAMMATIONINCLUDINGCONFLUENT BRIDGINGANDPANACINARNECROSIS

4ABLE)SHAKSMODIFIEDHISTOLOGICALACTIVITYINDEXM(!) ;=

INTERFACEHEPATITIS

    

NONE FOCAL FEWPORTALTRACTS FOCAL MAJORITYOFPORTALTRACTS CONTINUOUSOFPORTALTRACTS CONTINUOUSOFPORTALTRACTS

CONFLUENTNECROSES

      

NONE FOCAL FEWZONE NECROSIS MULTIPLEZONE NECROSIS ZONE ANDFEWPORTOCENTRALBRIDGINGNECROSIS ZONE ANDMULTIPLEPORTOCENTRALBRIDGINGNECROSIS PANACINARMULTIACINARNECROSIS

SINGLECELLNECROSES

    

NONE FOCUS-0&OBJECTIVE= TOFOCI-0& TOFOCI-0& FOCI-0&

PORTALINFLAMMATION

    

NONE MILD FEWORALLPORTALTRACTS MODERATE FEWORALLPORTALTRACTS MODERATE ALLPORTALTRACTS SEVERE ALLPORTALTRACTS

REVERSIBILITY ANDFUNCTIONALHEPATICRESERVEINCHRONICLIVERDISEASE4HUS THE STAGING OF CHRONIC HEPATITIS IS AN IMPORTANT HISTOLOGICAL CRITERION TO EVALUATEPROGNOSISANDTHERAPEUTICOPTIONSINDICATION WHICHINCLUDEBOTH INITIALANDTIME COURSEBIOPSIES$URINGTHELASTYEARS SEVERALNON INVASIVE TESTSHAVEBEENINTRODUCEDTOASSESSLIVERFIBROSIS;= BUTSOFARALLHAVE

#OMPARATIVEPATHOLOGY



&IGURE3TAGINGOFCHRONICHEPATITIS! &IBROUSEXTENSIONOFTHEPORTALTRACTSSTAGE " 0ORTAL AND SEPTAL FIBROSIS STAGE   # 0ORTAL AND SEPTAL FIBROSIS WITH FORMATION OF INCOM PLETEPSEUDOLOBULIANDARCHITECTURALDISTORTIONSTAGE $ #OMPLETECIRRHOTICREMODELLING STAGE 

FAILEDINIDENTIFYINGCLINICALLYRELEVANTSTAGESOFEARLYPROGRESSION INTHE EVALUATIONOFARCHITECTURALDISTORTION ANDINTHEMEASURINGOFFIBROSISIN FATTY LIVER DISEASE ADEQUATELY 3INCE THOSE PATIENTS HAVE A HIGH NEED FOR TREATMENT LIVER BIOPSY REMAINS THE GOLD STANDARD IN ROUTINE DIAGNOSTICS ;=!NALOGOUSTOTHEGRADINGSYSTEMS SEVERALSCORINGSYSTEMSHAVEBEEN PROPOSEDFORTHESTAGINGOFCHRONICHEPATITIS;  =4HESCOREACCORD INGTO$ESMETETAL4AB WHICHWASDEVELOPEDFROM3CHEUERSSCORE ;= DESCRIPTIVELYSEPARATESFIVESTAGESNONE MILD MODERATE SEVEREFIBRO SIS ANDCIRRHOSIS &IG!n$ 4HEADVANTAGESOFTHISSYSTEMINCLUDESIMPLE APPLICABILITY CLEAR DEFINITION AND COMPARABLY SMALL INTER AND INTEROB SERVERVARIABILITY;=/FNOTE $ESMETSSCOREDOESNOTDIFFERENTIATETHE EXTENT OF CIRRHOSIS THE FINAL STAGE OF FIBROSIS WHICH IS A LIMITATION OF ALL QUALITATIVESCORINGSYSTEMSINTRODUCEDSOFAR3INCEITISNOWWELL KNOWN THATEFFECTIVEANTIVIRALTHERAPYMAYLEADTOTHEREGRESSIONOFLIVERFIBROSIS ;= INTHERAPEUTICSTUDIESTHEUSEOFTHESEMIQUANTITATIVEFIBROSISSCORES SUCHASTHEONEESTABLISHEDBY#HEVALIERETAL4AB ISRECOMMENDED ;=



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

4ABLE3TAGINGOFCHRONICVIRALHEPATITISACCORDINGTO$ESMET3CHEURER;= SCORE

VERBAL

HISTOLOGICALFEATURES



NOFIBROSIS

NOPORTALFIBROSIS



MILDFIBROSIS

ENLARGEDPORTALTRACTSWITHOUTSEPTA



MODERATEFIBROSIS INCOMPLETEPORTOPORTALSEPTA PRESERVEDARCHITECTURE



SEVEREFIBROSIS

PORTALFIBROSISWITHSEPTAANDARCHITECTURALDISTORTIONDIFFER ENCESINCENTRALVEINnPORTALTRACTDISTANCES NOEVIDENCEOF COMPLETECIRRHOTICREMODELLING



CIRRHOSIS

PROBABLEORDEFINITECIRRHOTICREMODELLING

4ABLE3EMIQUANTITATIVE3EVERITY3CORE;= CRITERIUM

SCORE

VERBAL

  

NORMALORABSENCEOFVEINCIRRHOSIS MODERATELYTHICKENEDSTELLATEASPECTOFVEINWALL -ARKEDLYTHICKENEDWALLANNULARASPECTOFVEINWALLWITH NUMEROUSFIBROUSEXTENSIONSBETWEENHEPATOCYTES

PERISINUSOIDALFIBROSIS

  

NORMAL LOCALISEDFIBROSIS DIFFUSEFIBROSIS

PORTALTRACT

   

NORMAL ENLARGEDWITHOUTSEPTA ENLARGEDWITHSEPTA CIRRHOSIS

NUMBEROFSEPTA

   

NONE )SEPTAMM SEPTAMM NODULARORGANISATION

WIDTHOFSEPTA

   

THINANDORINCOMPLETE THICKANDLOOSECONNECTIVEMATRIX VERYTHICKANDDENSECONNECTIVEMATRIX BIOPSYAREA

CENTRALVEIN

$ETERMININGFACTORSOFHEPATITISCAUSEDBYHEPATOTROPICVIRUS 4HE GENERAL MECHANISMS OF VIRAL HEPATITIS INCLUDE HEPATOCELLULAR DAMAGE INFLAMMATORY CELL INFILTRATES AND REGENERATION 4HEY ARE COMMON TO ALL HEPATITIS VIRUS INFECTIONS 4HE DEVELOPMENT OF CHRONIC VIRAL HEPATITIS IS A RESULT OF THE INSUFFICIENCY OF THE HOST IMMUNE SYSTEM TO CLEAR THE AGENT 3EVERALVIRUSESHAVEDEVELOPEDMECHANISMSTHATFACILITATETHEIRESCAPEFROM THEHOSTDEFENSIVEMECHANISMS4HUS CHRONICITYANDITSCOURSEREPRESENTSA COMPLEXINTERPLAYBETWEENVIRALANDHOSTFACTORSDETERMININGTHEMORPHOL OGYANDFINALOUTCOMEOFAHEPATITISVIRUSINFECTION

#OMPARATIVEPATHOLOGY



#AUSATIVEAGENT )NCONTRASTTO("6INFECTION (#6INFECTIONBECOMESCHRONICINMOSTCASES WHICHISTHERESULTOFSEVERALFACTORS4HEDEGREEOFVIRALREPLICATIONINACUTE (#6 INFECTION IS COMPARABLY HIGH USUALLY SURPASSING THE CAPACITY OF THE IMMUNE SYSTEM!LTHOUGH A TYPE ) INTERFERON RESPONSE IS INITIATED BY THE INNATE IMMUNE SYSTEM IT OFTEN FAILS TO INDUCE VIRAL CLEARANCE IN VIVO DUE TOINTERACTIONSOF(#6PROTEINSWITHMEDIATORSOFTHEINTERFERONRESPONSE SYSTEM;=3OME(#6PROTEINSHAVEBEENSHOWNTOINHIBITTHEACTIVITYON .+ANDDENDRITICCELLS; =$URING(#6INFECTIONNUMEROUSQUASISPE CIESAREPRODUCEDDUETOTHEPOORPROOFREADINGPOTENTIALOFTHEVIRAL$.! POLYMERASE OVERWHELMINGTHECAPACITYOFTHEADAPTIVEIMMUNESYSTEM;= $ESPITETHESEVIRALMECHANISMS ABOUTOF(#6INFECTIONSARECLEARED DURINGTHEACUTEPHASE)MPORTANTLY THEADDITIONOFANTIVIRALTHERAPYLEADS TOANALMOSTCUREOFACUTE(#6INFECTION)NCONTRAST CHRONIC("6 INFECTION PERSISTS EVEN FOLLOWING SEROCONVERSION WHICH MAY BE DUE TO ("E!GSECRETIONPRODUCING4 CELLTOLERANCEANDDOWNREGULATIONOF("6 REPLICATION;=4HUS THEREISABALANCEBETWEENMINIMISEDVIRALREPLICATION AND CONTROL OF THE INFECTION BY THE CELLULAR AND HUMORAL IMMUNE SYSTEM RESULTINGINLIFE LONGPROTECTIVEIMMUNITY

(OSTFACTORS 7HETHERANACUTEHEPATITISRESOLVESORBECOMESCHRONICISULTIMATELYDETER MINEDBYTHEHOSTSDEFENSEMECHANISMSINCLEARINGTHEINFECTION4HE4 CELL RESPONSESEEMSTOPLAYAMAJORROLEINTHERESOLUTIONOFAHEPATOTROPICVIRAL INFECTIONANDPATIENTSSUFFERINGFROMCHRONICINFECTIONONLYSHOWANARROWED ANDTRANSIENT4 CELLRESPONSECOMPAREDTOTHOSEWHOCLEAREDTHEVIRUS; =/NEOFTHEBESTEXAMPLESINTHISREGARDISTHECOMMONCHRONICITYRATE IN INFANTS VERTICALLY INFECTED BY ("6 IN CONTRAST TO INFECTED ADULTS WHICH ISMAINLYDUETOTHEIMMATURITYOFTHEIMMUNESYSTEM!DDITIONALLY REAC TIVATIONOFAN("6INFECTIONMAYOCCURFOLLOWINGIMMUNOSUPPRESSIONDUE TOORGANTRANSPLANTATION; =)MPORTANTLY ("6ASWELLAS(#6INFEC TION MAY SHOW AN ATYPICAL RE INFECTION PATTERN AFTER LIVER TRANSPLANTATION KNOWN AS FIBROSING CHOLESTATIC HEPATITIS &#( WHICH TYPICALLY DEVELOPS WITHINTHEFIRSTMONTHAFTERTRANSPLANTATIONANDRAPIDLYLEADSTOGRAFTFAILURE (ISTOLOGICALLY &#(ISCHARACTERISEDBYHEPATOCELLULARBALLOONING CHOLESTA SISWITHPROMINENTDUCTULARPROLIFERATIONANDINTENSEPERISINUSOIDALFIBROSIS BUTTHEREISALACKOFSIGNIFICANTINFLAMMATORYCELLINFILTRATION)NTHECASEOF ("6 BALLOONEDHEPATOCYTESSHOWINTENSECYTOPLASMICANDNUCLEARSTAINING FOR("C!G SUGGESTINGMAXIMALVIRALREPLICATION; = 4HEPRESENCEOFCONCURRENTLIVERDISEASESMAYNEGATIVELYINFLUENCETHE PROGRESSION OF CHRONIC VIRAL HEPATITIS #ONSIDERING RECENT EPIDEMIOLOGIC DATA FATTYCHANGEEITHERINALCOHOLICORNON ALCHOLICFATTYLIVERDISEASEEG



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

OBESITY INSULIN RESISTANCE METABOLIC SYNDROME PROBABLY REPRESENTS THE MOST IMPORTANT ISSUES IN THIS CONTEXT SINCE IT HAS BEEN SHOWN THAT FATTY CHANGE CAUSES SINGLE CELL NECROSIS AND APOPTOSIS ACCELERATING FIBROSIS PRO GRESSION; =7HEREASPERIPORTALORMIDZONAL MACROVESICULARSTEATOSIS MAYBELONGTOTHESPECTRUMOF(#6INFECTIONESPECIALLYGENOTYPE ;= PERIVENULAR ACCENTUATION IS HIGHLY INDICATIVE OF AN ADDITIONAL ALCOHOLIC OR NON ALCOHOLICLIVERCELLDAMAGE ESPECIALLYWHENSEENINCOMBINATIONOFNON NECROSISASSOCIATEDPERISINUSOIDALFIBROSISANDOR-ALLORY $ENKBODIES !LTHOUGHENDOTHELIALIRONDEPOSITSHAVEBEENOBSERVEDINCHRONICVIRAL HEPATITIS HEPATOCELLULAR SIDEROSIS SHOULD RAISE THE QUESTION OF CONCURRENT GENETIC HAEMOCHROMATOSIS EG (&% MUTATION  #ONCURRENT LIVER DISEASE MAY BE OBSERVED IN UP TO  OF BIOPSIES OBTAINED FROM (#6 INFECTED INDIVIDUALS

!NIMALMODELS !NIMALMODELSANDNATURALOCCURRINGVARIANTSOFHUMANHEPATITIS VIRUSES (EPATITIS!VIRUS 3EVERALNONHUMANPRIMATEANIMALMODELSHAVEBEENUSEDFORSTUDYOF(!6 INFECTION BUTMOSTOFTHEDATACOMEFROMINOCULATIONEXPERIMENTSINTWO ANIMALSPECIESCHIMPANZEESANDTAMARINS3AGUINUSMYSTAX !DDITIONALLY SOME INFORMATION IS DERIVED FROM THE INFECTION OF OWL MONKEYS ;n= (ISTOLOGICAL CHANGES IN THE LIVER OF THESE ANIMALS CLOSELY RESEMBLE (!6 INFECTIONINMANINCLUDINGFOCALNECROSIS BALLOONINGDEGENERATION APOPTO SIS CHOLESTASIS AND+UPFFERCELLPROLIFERATION4HEINFLAMMATORYINFILTRATEIS MAINLYCOMPOSEDOFLYMPHOCYTES BUTNEUTROPHILS EOSINOPHILS ANDPLASMA CELLSAREALSOOBSERVED4HESEVERITYOFHEPATITISRANGESFROMMILDWITHFOCAL NECROSIS TO MODERATE WITH BRIDGING NECROSIS AND ALL ANIMALS RECOVER COM PLETELY)NCONTRASTTOHUMANS ANIMALSAREALMOSTNEVERSYMPTOMATICDURING EXPERIMENTAL(!6INFECTION;=

(EPATITIS%VIRUS -ACAQUE SPECIES CHIMPANZEES AND OWL MONKEYS ARE THE MOST FREQUENT ANIMALMODELSUSEDFORSTUDYOF(%6 BUTADDITIONALLY PIGSANDRATSMAY BEUSEFULFORSOMESTUDIES(ISTOLOGICALCHANGESINTHELIVEROFNONHUMAN PRIMATES AND HUMANS ARE SIMILAR 4HERE IS FOCAL CYTOLYTIC NECROSIS WITH MINIMALINFLAMMATORYINFILTRATIONINBOTHSPECIES)NFLAMMATORYINFILTRATES IF PRESENT CONSIST MAINLY OF NEUTROPHILS #HOLESTATIC HEPATITIS BALLOONING HEPATOCELLULAR CHOLESTASIS IS COMMON AND PSEUDOGLAND FORMATION HAS

#OMPARATIVEPATHOLOGY



BEENREPORTED; =4HEMORTALITYOFHEPATITIS%INTHETHIRDTRIMESTEROF PREGNANCYINHUMANSISREPORTEDTOBEAPPROXIMATELY WHICHISMUCH HIGHER THAN IN PREGNANT RHESUS MONKEYS ; =!DDITIONALLY IN CONTRAST TO HUMANS IN WHOM IMMUNITY DEVELOPS RECURRENT HEPATITIS % HAS BEEN REPORTEDINTAMARINS;=

(EPATITIS"VIRUS .ATURAL ANIMAL MODEL SYSTEMS FOR THE STUDYING OF ("6 INFECTION CAN BE DIFFERENTIATEDINTHOSEBEINGPERMISSIVEFORHUMAN("6ANDTHOSEINFECTED BY("6 RELATEDVIRUSES #HIMPANZEES CAN BE INFECTED WITH ("6 AND THIS MODEL CONTRIBUTED MUCH TO OUR CURRENT UNDERSTANDING OF THE MOLECULAR VIROLOGY OF CHRONIC HEPATITIS"4HEADVANTAGESOFTHISMODELINCLUDETHEFACTTHATITISTHEONLY MODEL FOR IMMUNOLOGICAL STUDIES OF THE NATURAL COURSE OF THE INFECTION THE POSSIBILITY TO USE DEFINED INOCULA AND STUDY THE EARLY PHASES OF INFEC TION 4HE DISADVANTAGES OF THIS MODEL ARE ETHICAL CONSIDERATIONS LIMITING BIOMEDICALRESEARCHONPRIMATES COMPARABLYHIGHCOSTSANDLIMITEDAVAIL ABILITY OF CHIMPANZEES LISTED AS AN ENDANGERED SPECIES SINCE   4HE CLINICALCOURSEOFTHEINFECTIONISONLYVERYMILDANDTHEHUMORALIMMUNE RESPONSE IS WEAK AND MORE RESTRICTED COMPARED TO HUMANS!DDITIONALLY VERTICAL TRANSMISSION OCCURS ONLY RARELY IN CONTRAST TO ("6 IN HUMANS  )N CHIMPANZEES THERE ARE TWO HISTOLOGICALLY DISTINCTIVE TYPES OF INFECTION THE FIRST TYPE IS A SELF LIMITING ACUTE HEPATITIS4HE SECOND TYPE RESULTS IN CHRONIC HEPATITIS WITH PORTAL LYMPHOCYTIC INFILTRATION FORMATION OF LYM PHOIDFOLLICLESUSUALLYNOTSEENINHUMANS ANDVARIABLE USUALLYMILDLIVER CELLNECROSIS)NTERFACEHEPATITISISGENERALLYNOTSEENIN("6 INFECTEDCHIM PANZEES 4HEREFORE CHIMPANZEES DO NOT DEVELOP PROGRESSIVE FIBROSIS AND LIVERCIRRHOSIS; =)THASBEENSHOWNTHATINFECTIONWITH("6 RELATED VIRUSESNATURALLYMAYTAKEPLACEINCHIMPANZEES GIBBONS ORANG UTANS AND RHESUSMONKEYS BUTTHESEANIMALSDONOTSEEMTODEVELOPMORPHOLOGICAL EQUIVALENTSOFHEPATITIS;n=!NOTHERTRANSIENTLY("6 INFECTIBLEANIMAL MODELREPRESENTSTHETREESHREWSPECIES4UPAIABELANGERI;= WHICHDEVEL OPSSHORT TERMREPLICATIONFOLLOWEDBYSEROCONVERSION BUTDOESNOTSHOW HISTOLOGICALCHANGESOFHEPATITIS ("6 RELATED VIRUSES CAN BE GROSSLY DIVIDED IN MAMMALIAN HEPATITIS VIRUSES ORTHOHEPADNAVIRUSES AND AVIAN HEPATITIS VIRUSES AVIHEPADNAVI RUSES 4HEFIRST("6 RELATEDVIRUSDESCRIBEDWASTHEWOODCHUCKHEPATITIS VIRUS 7(6 WHICH CAUSES CHRONIC HEPATITIS WITH SOME INTERFACE ACTIVITY COMPARABLETOTHATINHUMANSWITHCHRONIC("6INFECTION ALTHOUGHINFLAM MATORY ACTIVITY IS GENERALLY MILDER !DDITIONALLY 7(6 INFECTED WOOD CHUCKS DEVELOP HEPATOCELLULAR CARCINOMA (## WITH HIGHER FREQUENCY BUTINCONTRASTTOHUMANS THEYDONOTDEVELOPLIVERCIRRHOSIS; =/THER MAMMALIAN("6 RELATEDVIRUSESINCLUDETHEGROUNDSQUIRRELHEPATITISVIRUS



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

'3(6 ; = THEARCTICSQUIRRELHEPATITISVIRUS!3(6 ANDTHEWOOLLY MONKEY HEPATITIS " VIRUS 7-(6  )N GENERAL ALL OF THESE ANIMALS SHOW ONLY MILD HISTOLOGICAL LIVER ABNORMALITIES DESPITE SOMETIMES HIGH SERUM TITRESAND(##DEVELOPMENTISSEENINFREQUENTLY; =7OOLLYMONKEY HEPATITIS " VIRUS 7-("6 USUALLY CAUSES CHRONIC HEPATITIS WITH NO OR MINORSYMPTOMS BUTFULMINANT7-("6HEPATITISMAYOCCUR4HEDEVELOP MENTOFLIVERCIRRHOSISHASNOTBEENREPORTED;=!BOUTONE THIRDOFAGED ARCTICSQUIRRELSDEVELOPFOCALLIVERLESIONS WHICHINCLUDELIVERCELLADENOMAS (##S ANDLARGENODULESSHOWINGMICROVESICULARSTEATOSIS;=)MPORTANTLY THESELESIONSAREALSOOBSERVEDINANIMALSNOTINFECTEDWITHTHEARCTICSQUIR RELHEPATITISVIRUS!3(6 4HUS THISMODELDIFFERSSIGNIFICANTLYFROM7(6 INFECTION INWHICHMOSTINFECTIONSRESULTIN(##DEVELOPMENTWITHINn YEARS;= 4HEGROUPOFAVIHEPADNAVIRUSESINCLUDETHEPROTOTYPICDUCKHEPATITIS" VIRUS$("6 ANDSEVERALRELATEDFAMILYMEMBERSHERONHEPATITIS"VIRUS (("6 SNOWGOOSEHEPATITISVIRUS3'(6 ROSSGOOSEHEPATITIS"VIRUS 2'("6 WHITESTORKHEPATITIS"VIRUS73("6 ANDCRANEHEPATITIS" VIRUS;n=$("6INFECTIONCAUSESANACUTEHEPATITISANDITSSEVERITYCOR RELATESWITHTHEDEGREEOFVIREMIA BUTINCONTRASTTOMAMMALIANHEPATITIS VIRUSES ONLYVERYMILDOREVENNOHISTOLOGICALCHANGESOCCURDURING$("6 PERSISTENCE(##DEVELOPMENTHASBEENOBSERVEDIN$("6 INFECTED0EKIN DUCKS BUTONLYINAFEWCASESSUCHTHATITSRELATIONTO$("6ISQUESTIONABLE ; n=

(EPATITIS$VIRUS 3INCE($6REPRESENTSANINCOMPLETEVIRUS WHICHHASANABSOLUTEREQUIRE MENTFOR("6FORREPLICATIONANDTRANSMISSION ANIMALMODELSARERESTRICTED TOTHOSEPERMISSIVEFOR("6INFECTION;="OTHINHUMANSANDINANIMAL MODELS THEREPLICATIONOF("6ISDIMINISHEDDURINGACUTE($6REPLICATION ($6INFECTIONMAYEITHEROCCURASACO INFECTIONWITH("6ORASASUPERIN FECTIONIN("6CARRIERS)NTHECHIMPANZEEMODEL CO INFECTIONRESULTSINA MODERATELYACTIVEHEPATITIS WHICHMAYSHOWTWODIFFERENTCOURSES7HEREAS INTHEUNIMODALCOURSEOFDISEASETHEREISPARALLELEXPRESSIONOF("CAND DELTA ANTIGEN IN THE NUCLEI OF INFECTED HEPATOCYTES THE BIMODAL INFECTION IS CHARACTERISED BY THE EXPRESSION OF ONE OR THE OTHER ANTIGEN DURING THE SECONDPHASE;=)NCONTRAST ASUPERINFECTIONOF($6RESULTSINAMORE SEVEREHEPATITIS WHICHINMORETHANOFCASESRESULTSINVIRALPERSISTENCE ;= !DDITIONALLY THE ($6 GENOTYPE SEEMS TO INFLUENCE THE SEVERITY OF LIVERDISEASE;=!LTHOUGH($6INFECTIONRESULTSINAMORESEVEREHEPATITIS INCHIMPANZEESCOMPAREDTOOTHERHEPATITISVIRUSES THEYDONOTDEVELOPA PROGRESSIVEDISEASECOMPAREDTOTHEONESEENINHUMANS !LTHOUGH THERE IS NO INDICATION THAT ($6 INFECTION MAY TAKE PLACE NATURALLYIN7(6INFECTION ITHASBEENSHOWNTHAT($6CANBETRANSMITTED

#OMPARATIVEPATHOLOGY



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'"VIRUSES '"VIRUSES!AND"'"6 !AND'"6 " AREMEMBERSOFTHE&LAVIVIRIDAE FAMILYANDWEREISOLATEDFROMTAMARINSINFECTEDWITHSERUMFROMAHUMAN HEPATITISPATIENT; =!THIRDMEMBEROFTHISGROUPREPRESENTSARELATED HUMANVIRUS '"VIRUS# ORALTERNATIVELY HEPATITIS'VIRUS'"6 #('6 ; = '"6 !HASBEENSHOWNTOBEACOMMON.EW7ORLDPRIMATEVIRUSCAUS INGCHRONICINFECTIONWITHOUTAPPARENTLIVERDISEASE;='"6 " WHICHIS PHYLOGENETICALLY RELATED TO HUMAN (#6 ;= IS CAPABLE OF CAUSING ACUTE HEPATITIS IN TAMARINS ;= 3INCE INDIGENOUS ISOLATES OF '"6 " HAVE NOT BEENISOLATEDFROMWILDTAMARINS ITSEEMSQUESTIONABLEWHETHERTAMARINS ARETHENATURALHOST'"6 #('6SEEMSTOBEALYMPHOTROPICVIRUSRATHER THAN A HEPATOTROPIC VIRUS 0HYLOGENETICALLY IT IS MORE RELATED TO '"6 ! THAN'"6 " '"6 " APLEIOTROPICVIRUS HASBEENPROPOSEDASAPOTENTIALMODELFOR THESTUDYOFHUMAN(#6INFECTION SINCEITISPHYLOGENETICALLYMOSTCLOSELY



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

RELATED TO (#6 AND CAUSES AN ACUTE SELF RESOLVING HEPATITIS IN TAMARINS RESULTING IN AN INCREASE IN ALANINE AMINOTRANSFERASE AND MILD HEPATITIC CHANGES IN LIVER HISTOLOGY )MPORTANTLY '"6 " DOES NOT CAUSE CHRONIC HEPATITISINTAMARINS WHICHISDIFFERENTFROM(#6INHUMANS!DDITIONALLY '"6 "INFECTIONCAUSESPROTECTIVEIMMUNITYAFTERRESOLUTIONOFTHEINFEC TION WHICHISNOTTHECASEINRESOLVEDHUMANHEPATITIS#;=

4RANSGENICMOUSEMODELS !LTHOUGH TRANSGENIC AND OTHER MOUSE MODELS HAVE ELUCIDATED SOME IMPORTANTASPECTSOFTHEPATHOGENESISOFVIRALHEPATITIS THEYHAVESEVERAL LIMITATIONS MURINE HEPATOCYTES ARE NOT PERMISSIVE FOR HUMAN HEPATITIS VIRUS INFECTIONS 4HEREFORE STUDIES OF THE COMPLETE NATURAL LIFE CYCLE OF HEPATITIS VIRUSES ARE NOT POSSIBLE USING THESE SYSTEMS 4HEREFORE MOST OF THESE MICE DO NOT EXHIBIT A LIVER SPECIFIC PHENOTYPE AND STUDIES ON VIRUS RELATED IMMUNE MEDIATEDMECHANISMSOFLIVERINJURYARERESTRICTED )NDUCIBLESYSTEMSEG T4! #RELOX0 MAYOVERCOMETHISPROBLEMINTHE NEARFUTURE4HEDESCRIPTIONOFTHEENTIRESPECTRUMOFTRANSGENICMODELSOF VIRALHEPATITISISBEYONDTHESCOPEOFTHISCHAPTER4HEREFORE ONLYGENERAL REMARKSAREGIVENANDSOMEINTERESTINGFACTSDERIVINGFROMTHESEMODELS AREPRESENTED 3EVERALTRANSGENICMOUSESTRAINSEXPRESSINGPARTIALORCOMPLETECOPIES OF THE ("6 GENOME HAVE BEEN DEVELOPED ;n= ("6 TRANSGENIC MICE INOCULATED WITH ($6 DEVELOP VIRAL REPLICATION AND ASSEMBLE NEW ($6 PARTICLES;=2ECENTLY ATRANSGENICMOUSEMODELFORCHRONICHEPATITISWAS DEVELOPED;=)NTHISMODEL CHRONICLIVERDISEASERESULTEDFROMTHEADOP TIVETRANSFEROFUNPRIMED SYNGENEICSPLENOCYTESIN("6 TRANSGENICIMMU NODEFICIENT3#)$MICE!SARESULT THE("SANTIGENANDVIRAL$.!WERE CLEARED WITHIN A FEW WEEKS WHICH WERE OFTEN ACCOMPANIED BY ("S ANTI BODYSEROCONVERSION BUTITDIDNOTRESULTINCOMPLETEVIRALELIMINATIONAS INDICATEDBYTHEREAPPEARANCEOF("6$.!ATALATERTIME(ISTOLOGICALLY THELIVERSOFTHESEMICESHOWEDPORTALINFLAMMATION ACINARINFLAMMATION HEPATOCELLULAR DEGENERATION AND REGENERATION AS SEEN IN HUMAN CHRONIC VIRALHEPATITIS

#HIMERICMOUSEMODELS 4HERE ARE BASICALLY TWO DIFFERENT CHIMERIC MOUSE MODELS THE FIRST REPRE SENTS THE 4RIMERA MOUSE MODEL WHICH IS DEVELOPED VIA PRECONDITIONING OF NORMAL MICE BY LETHAL BODY IRRADIATION AND RADIOPROTECTION BY 3#)$ MOUSEBONEMARROWTRANSPLANTATION3UBSEQUENTLYEXVIVOINFECTEDHUMAN LIVERTISSUEFRAGMENTSAREIMPLANTEDUNDERTHEKIDNEYCAPSULEORINTHEEAR PINNAOF4RIMERAMICE;=!MODIFICATIONOFTHISMODELISTHENON OBESE

#OMPARATIVEPATHOLOGY



DIABETICSEVERE COMBINED IMMUNODEFICIENCY ./$3#)$ MOUSE TRANS PLANTEDWITHHUMANLIVERTISSUE;= 4HESECONDMOUSEMODEL OFWHICHSEVERALMODIFICATIONSEXIST ISBASED ON THE ALBUMIN UROKINASETYPE PLASMINOGEN ACTIVATOR U0! TRANSGENIC MOUSE4HISMOUSEDEVELOPSALIVER AUTO TOXICPHENOTYPEWITHPROGRESSIVE DEPLETIONOFTRANSGENE BEARINGHEPATOCYTESANDRECONSTITUTIONOFTHELIVER PARENCHYMA BY TRANSGENE DEFICIENT HEPATOCYTES VIA TRANSGENE REARRANGE MENTBYMONTHSOFAGE;=7HENTHESEMICEARECROSS BREDWITH2!'  DEFICIENT MICE LACKING MATURE 4 AND " LYMPHOCYTES ;= HEPATOCYTES MAY XENOGRAFT THE LIVERS OF THE COMPOUND TRANSGENICS EG WOODCHUCK HUMAN TREESHREW ;n=2ECENTLYADERIVATIVEMODEL THEU0!3#)$ MOUSE WAS CHARACTERISED WHICH SHOWS OCCUPATION OF UP TO NEARLY  OF THE LIVER PARENCHYMA BY EXPANDED ENGRAFTED HUMAN HEPATOCYTES ; =4HE ADVANTAGE OF THESE CHIMERIC SYSTEMS IS THE ABILITY TO STUDY VIRAL REPLICATION AND VIRAL SPREAD IN VIVO IN AN ANIMAL SYSTEM WHICH ALLOWS FOR THERAPEUTICANDVACCINATIONSTUDIESINASMALLANIMALSYSTEM.EVERTHELESS CHRONICVIRALHEPATITISCANNOTBEEVALUATEDINTHISMODELDUETOTHEIMMU NODEFICIENCYBACKGROUNDOF2!'  RESPECTIVELY3#)$ MICE

#LINICALLYRELEVANTHEPATITISINDOMESTICANIMALS #HRONICLIVERDISEASEINDOGSISSIMILARTOCHRONICHEPATITISINHUMANSINTHAT THEREAREMANYDIFFERENTETIOPATHOLOGICALFACTORSSUCHASTHECANINEADENO VIRUS TYPE  ,EPTOSPIROA INTERROGANS VAR GRIPPOTYPHOSA CANINE ACIDOPHIL CELL HEPATITIS VIRUS COPPER ACCUMULATION _ ANTITRYPSIN DEFICIENCY DRUG TOXICITY AND AUTOIMMUNITY ALTHOUGH IN MANY CASES THE ETIOLOGICAL CAUSE REMAINSOBSCURE;n=(ISTOLOGICALLY CANINECHRONICHEPATITISISCOM PARABLE TO HUMAN HEPATITIS AND SHOWS PORTAL INFLAMMATION WITH INTERFACE HEPATITISASWELLASANACINARINFLAMMATORYCOMPONENTANDPROGRESSIONTO LIVERCIRRHOSIS; = !TYPICALFREQUENTLYFATALHEPATITISHASBEENREPORTEDINLAMBSBYOVINE ADENOVIRUSTYPE;=3IMIAN6ARICELLA6IRUSMAYCAUSEFULMINANTHEPATI TISIN/LD7ORLDMONKEYS WHICHHISTOLOGICALLYSHOWSSIMILARITIESTO6ARICELLA ZOSTERVIRUSHEPATITISINHUMANSNUCLEARINCLUSIONS ;=

#ONCLUDINGREMARKS !LTHOUGHLIVERBIOPSYMAYBEAVALUABLETOOLINEVALUATINGACUTEHEPATITIS IN HUMANS ESPECIALLY IN TRANSPLANTS IN WHICH SPECIFIC HISTOLOGICAL FEATURES MAY FACILITATE EXPEDITIOUS DIAGNOSIS AND ADEQUATE TREATMENT LIVER BIOPSY REPRESENTS THE GOLD STANDARD IN THE ASSESSMENT OF CHRONIC HEPATITIS SINCE IT PROVIDES CLUES FOR THE DIAGNOSIS PROGNOSIS GRADING STAGING AND THERA PEUTICOPTIONS-ANYSMALLANDLARGEANIMALMODELSINCLUDINGTRANSGENICS



4HOMAS,ONGERICHAND0ETER3CHIRMACHER

HAVEBEENDEVELOPEDFORSTUDIESONCHRONICVIRALHEPATITIS WHICHHAVEELUCI DATEDIMPORTANTASPECTSOFTHEMOLECULARBIOLOGYANDPATHOGENESISOFVIRAL HEPATITIS .EVERTHELESS THE HISTOLOGICAL DISEASE COURSE IN ANIMALS DIFFERS FROM THAT IN HUMANS IN THAT THE DEGREE OF INFLAMMATORY ACTIVITY IS GENER ALLYMILDERANDTHEDEVELOPMENTOFLIVERFIBROSISORCIRRHOSISISRARELYSEEN &UTURE DEVELOPMENTS EG INDUCIBLE TRANSGENIC MODELS MAY ALLOW CLOSER SIMULATIONOFTHEHUMANSITUATIONANDHELPTOIMPROVEOURUNDERSTANDING OFTHEPATHOGENESISANDPROGNOSISOFCHRONICHEPATITIS

2EFERENCES 

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!BSTRACT 4HE HUMAN HEPATITIS " VIRUS ("6 IS THE PROTOTYPE MEMBER OF THE FAMILY OF HEPAD NAVIRIDAE SMALL ENVELOPED VIRUSES WHICH REPLICATE THEIR COMPACT AND HIGHLY ORGANIZED $.!GENOMEVIAREVERSETRANSCRIPTION)NHUMANS ("6MAYCAUSEINFLAMMATORYLIVER DISEASE HEPATITIS"7ITHMORETHANMILLIONCHRONICALLYINFECTEDPEOPLEATHIGHRISK TODEVELOPLIVERCIRRHOSISORHEPATOCELLULARCARCINOMA ("6ISONEOFTHEMOSTIMPORTANT HUMANPATHOGENS)NRECENTYEARS THEVIRALLIFECYCLEHASBEENCHARACTERISEDINCONSIDER ABLEDETAIL OURUNDERSTANDINGOFIMMUNOLOGYANDPATHOGENESISOFHEPATITIS"HASLARGELY IMPROVED AND NUCLEOST IDE ANALOGUES HAVE BEEN ESTABLISHED AS ANTIVIRALS (OWEVER CURRENTTREATMENTOPTIONSARESTILLLIMITEDBECAUSE THEY ONLY RARELY ELIMINATE THE VIRUS ANDTHUSLONG TERMTREATMENTISREQUIRED&OLLOWINGAGENERALINTRODUCTION WETHEREFORE DISCUSSWHICHSTEPSINTHEVIRALLIFECYCLEMAYSERVEASTARGETSFORNOVELTHERAPEUTICSTRATE GIES

4HEHUMANHEPATITIS"VIRUS 4HEHUMANHEPATITIS"VIRUS("6 ISTHEPROTOTYPEMEMBEROFAFAMILYOF SMALLENVELOPED$.!VIRUSES!LLMEMBERSOFTHISFAMILYARECHARACTERISED BY A PRONOUNCED LIVER TROPISM AND THEY ARE THEREFORE SUBSUMEDLY NAMED HEPADNAVIRUSES FOR HEPATOTROPIC $.! VIRUSES  ("6 IS A NON CYTOPATHIC VIRUS SINCE ITS ASSEMBLY IN HEPATOCYTES PROCEEDS WITHOUT CELL DISRUPTION 4HUS ("6 PRODUCING CELLS CONTINUOUSLY RELEASE PROGENY VIRAL PARTICLES 4HISHASBEENDEMONSTRATEDINSTABLYTRANSFECTEDHEPATOMACELLLINES;=AS WELLASIN("6 TRANSGENICMICE;=ANDEXPLAINSWHY("6INFECTIONPERSE DOES NOT CAUSE LIVER DAMAGE )T ALSO EXPLAINS WHY ("6 ELICITS LITTLE OR NO INNATEIMMUNERESPONSES;=7HENTHEADAPTIVEIMMUNESYSTEMBECOMES ACTIVATED HOWEVER INFLAMMATORY LIVER DISEASE CALLED HEPATITIS " BECOMES EVIDENT AND THE INFECTION MAY BE CLEARED 4HIS USUALLY HAPPENS IF ADULTS BECOMEINFECTED BUTOFTENISMISSINGDURINGNEONATALINFECTION



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4HE VIRAL GENOME  KB CONSISTING OF A PARTIALLY DOUBLE STRANDED RELAXEDCIRCULARRC $.!SHOWSANEXTREMELYCOMPACTORGANISATIONWITH OVERLAPPINGOPENREADINGFRAMESOFTHEVIRALPOLYMERASEANDSTRUCTURALPRO TEINSENCODINGTHEVIRALCAPSIDANDTHETHREEENVELOPEPROTEINS)NADDITION REGULATORY ELEMENTS LIKE PROMOTERS ENHANCERS AND THE POLYADENYLATION SIGNAL OVERLAP WITH CODING SEQUENCES ;= ,IKE THE ANIMAL HEPADNAVIRUSES EG DUCKHEPATITIS"VIRUS$("6 WOODCHUCKHEPATITIS"VIRUS7(6 ("6MULTIPLIESITSGENOMEBYREVERSETRANSCRIPTIONOFAN2.!PREGENOME &IG  ;= &OLLOWING FUSION OF THE VIRAL AND THE CELLULAR MEMBRANE THE NUCLEOCAPSIDISTRANSPORTEDTOTHENUCLEARPORECOMPLEXWHERETHERC$.! GENOME IS RELEASED INTO THE HEPATOCYTE NUCLEUS )NSIDE THE NUCLEUS THE RC$.!ISCONVERTEDTOACOVALENTLYCLOSEDCIRCULAR$.!CCC$.! BYCEL LULARENZYMESCCC$.!ENCODESFOURUNIDIRECTIONAL OVERLAPPINGOPENREAD ING FRAMES AND CONSTITUTES THE TRANSCRIPTION TEMPLATE FOR THE PREGENOMIC ANDTHESUBGENOMIC2.!S 4HE PREGENOMIC 2.! SERVES AS M2.! FOR THE VIRAL CORE AND POLY MERASEPROTEINS)NADDITION ITCONTAINSAHAIRPIN LOOPATTHE END WHICH TRIGGERSITSENCAPSIDATIONTOGETHERWITHTHEVIRALPOLYMERASEINTOANICOSA HEDRALNUCLEOCAPSID4HENUCLEOCAPSIDINTHEVIRIONCONSISTSOFSUBUNITS OF THE ("6 CORE PROTEIN WHICH ORGANISE TO SOME EXTENT THE SURROUNDING ENVELOPE PROTEINS ;=4HE VIRAL ENVELOPE IS BUILT OF A LIPID BILAYER AND IS DENSELYPACKEDWITHTHELARGE, MIDDLE- ANDnPREDOMINANTLYnSMALL 3 SURFACEPROTEINS4HESEPROTEINSARETRANSLATEDFROMTHREESUBGENOMIC M2.!S )N ADDITION ("6 AND OTHER MAMMALIAN HEPADNAVIRUSES ENCODE A REGULATORY PROTEIN CALLED 8 WHICH IS REQUIRED TO ESTABLISH INFECTION IN VIVOINWOODCHUCKS; =ANDDISPLAYSPLEIOTROPICEFFECTSWHENSTUDIEDIN CELLCULTURE BASEDASSAYS)NFECTEDCELLSSECRETEnINHIGHEXCESSTOCOMPLETE VIRIONSnSUBVIRALPARTICLES WHICHAREEMPTYENVELOPESOFSPHERICALNM PARTICLES ANDFILAMENTOUSSHAPE3PHERESCONTAINMOSTLYTHE3PROTEINAND CANBEDETECTEDINTHESERUMOFINFECTEDINDIVIDUALSASHEPATITIS"SURFACE ANTIGEN ("S!G  4HE ("6 PRECORE PROTEIN WHOSE CODING SEQUENCE ENCOMPASSESTHATOFTHECOREPROTEIN ISNOTREQUIREDFOR("6REPLICATION ORINFECTION BUTITISPROCESSEDANDSECRETEDFROMINFECTEDCELLSAS("E!G ; =

(EPATITIS"VIRUSINFECTIONANDRELATEDDISEASE ("6 INFECTS LIVERS OF HUMANS HUMANOID PRIMATES LIKE CHIMPANZEES ;= ANDGORILLAS ANDSURPRISINGLY4UPAIABELANGERI ASMALLMAMMALBELONGING TOTHEORDERSCANDENTIA; =$EPENDINGONTHEHOSTIMMUNERESPONSE THEVIRUSESTABLISHESEITHERTRANSIENTORPERSISTENTINFECTION("6ISTRANS MITTEDBYPERINATAL PERCUTANEOUS ANDSEXUALTRANSMISSIONROUTES ASWELL AS BY CLOSE INTERINDIVIDUAL CONTACT DURING EARLY INFANCY4HE LATTER OCCURS PRESUMABLYBYOPENCUTSORSORES;=6ERTICALTRANSMISSIONFROMMOTHERSTO

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&IGURE ("6ATTACHESVIATHEPRE3 DOMAINOFTHE, PROTEINTOHEPARANSULFATE PROTEOGLY CANSOFTHEHEPATOCYTESURFACE !FTERENDOCYTOSISBYANUNKNOWNMECHANISM FUSIONOFTHE VIRALANDTHEVESICULARMEMBRANESOCCURS ANDTHE$.! CONTAININGNUCLEOCAPSIDISRELEASED  !FTERTRANSPORTTOTHENUCLEUSPROBABLYALONGTHECYTOSKELETONOFTHEHEPATOCYTE  AND RELEASE OF THE CAPSID INTO THE NUCLEAR PORE COMPLEX  THE PARTIALLY DOUBLE STRANDED $.! ENTERS THE NUCLEUS AND IS CONVERTED TO THE COVALENTLY CLOSED CIRCULAR CCC $.! BY CELLULAR ENZYMES !FTER0OL )) MEDIATEDTRANSCRIPTION ANDEXPORT OFTHEPREGENOMIC2.! PG2.! INTOTHECYTOPLASMTRANSLATIONOFCOREPROTEINANDTHE("6POLYMERASEOCCURS  !FTERSELFASSEMBLYOFTHECOMPLEXOFPG2.! POLYMERASEANDCOREPROTEININTOAN2.! CON TAININGNUCLEOCAPSID REVERSETRANSCRIPTIONOFTHEPG2.!TOAMATUREGENOMETAKESPLACE  4HIS $.! CONTAINING NUCLEOCAPSID CAN EITHER BE RE IMPORTED INTO THE NUCLEUS  OR ENVELOPEDBYTHE("6SURFACEPROTEINSATTHE%2MEMBRANE 4HESESURFACEPROTEINSHAVE BEENSYNTHESISEDFROMINDEPENDENTLYTRANSCRIBEDANDEXPORTEDSUBGENOMIC2.!S%XOCYTOSIS OFAUTONOMOUSLYASSEMBLEDSUBVIRALPARTICLESANDPROGENYVIRIONSPROCEEDSVIATHESECRETORY PATHWAYBYASTILLILLUNDERSTOODROUTE 

THEIRNEONATES ORINFECTIONDURINGTHEFIRSTYEAROFLIFE RESULTSININ PERSISTENT OFTENLIFE LONGINFECTION)NCONTRAST INFECTIONDURINGADULTHOOD IS CLEARED IN  OF CASES AND RESULTS IN LIFE LONG PROTECTIVE IMMUNITY ;= )NHUMANS ("6INFECTIONMAYCAUSEINFLAMMATORYLIVERDISEASEnHEPA TITIS"7ORLDWIDE MORETHANMILLIONPERSONSAREPERSISTENTLYINFECTED #HRONIC("6INFECTIONMAYBESYMPTOMATICORASYMPTOMATIC0ERSISTENTLY



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INFECTEDINDIVIDUALSWITHOUTSIGNIFICANT ONGOINGNECROINFLAMMATORYDISEASE ARE TERMED ("S!G CARRIERS .ECROINFLAMMATORY DISEASE IS DEFINED BY THE PRESENCE OF INFLAMMATORY ACTIVITY ANDOR FIBROSIS IN LIVER TISSUE BIOPSIES ANDOFTENDETECTEDBYANELEVATEDSERUMTRANSAMINASEACTIVITY)NDIVIDUALS IN WHOM THE VIRUS PERSISTS FOR MORE THAN SIX MONTHS AND IN WHOM ("6 CAUSES CHRONIC NECROINFLAMMATORY DISEASE ARE CLASSIFIED AS HAVING CHRONIC HEPATITIS" 4HEONGOINGINFLAMMATIONINCHRONICHEPATITIS"RESULTSINLIVERCIRRHOSIS ANDHEPATOCELLULARCARCINOMAINMORETHANOFPATIENTS;=/FCHRONIC HEPATITIS"PATIENTS nWILLDEVELOPSERIOUSSEQUELAEDURINGTHEIRLIFE TIME ACCOUNTINGFORTOMILLIONDEATHSPERYEARWORLDWIDE;=

)MMUNERESPONSETO("6 6IRALCLEARANCEDURINGSELF LIMITED("6INFECTIONISCHARACTERISEDBYAVIG OROUS POLYCLONALANDMULTISPECIFIC#$AND#$4 CELLRESPONSETOVIRAL PROTEINS ; = )N CONTRAST A WEAK AND OLIGOCLONAL4 CELL RESPONSE WAS DESCRIBEDINPERSISTENTLYINFECTEDINDIVIDUALS; =4HUS INPATIENTSWHO DEVELOPCHRONICINFECTIONEITHERNOSUFFICIENT4 CELLRESPONSEISINDUCEDOR ANINITIALLYVIGOROUS4 CELLRESPONSEISDIMINISHED )NSELF LIMITEDEXPERIMENTAL("6INFECTIONSINCHIMPANZEESATWO PHASIC 4 CELLRESPONSEHASBEENOBSERVED)NTHEINITIALPHASE4 CELLSCONTROLVIRAL REPLICATIONANDANTIGENEXPRESSIONINANON CYTOTOXICFASHIONBYTHESECRE TIONOFCYTOKINESWITHINTERFERON)&. aBEINGTHEMAINPLAYER(EREBY THE NUMBEROFANTIGEN POSITIVEHEPATOCYTESASAPOTENTIALTARGETOF4 CELLKILLING ISREDUCED)NASECONDPHASE THECYTOTOXICACTIVITYOF4 CELLSISPREDOMINANT ANDREMAININGINFECTEDCELLSAREELIMINATED; = 4RANSLATION OF VIRAL PROTEINS DURING REPLICATION RESULTS IN THE PROCESS ING OF VIRUS DERIVED PEPTIDES 4HESE PEPTIDES ARE PRESENTED BY MAJOR HISTOCOMPATIBILITY ANTIGENS CLASS ) -(# ) MOLECULES ON THE SURFACE OF INFECTED HEPATOCYTES #YTOTOXIC 4 CELLS WHICH RECOGNISE THESE ANTIGENS IN THECONTEXTOFTHERESPECTIVE-(#)MOLECULE MAYBEACTIVATEDTOKILLTHE INFECTEDCELLEITHERBYSECRETIONOFPERFORINANDGRANZYMEORBYINDUCTION OFAPOPTOSIS3INCE("6INFECTEDCELLSCONTINUOUSLYEXPRESSVIRALPROTEINS THEYAREPOTENTIALTARGETSOF4 CELLKILLING IFACTIVATED4 CELLSGAINACCESSTO THEINFECTEDCELLS 4HE FAILURE TO INDUCE OR MAINTAIN A VIGOROUS4 CELL RESPONSE IS ASTON ISHING SINCE HUGE AMOUNTS OF ("S!G AND ("E!G CIRCULATE IN THE BLOOD OFINFECTEDPATIENTS4HEMAJORITYOF4 CELLEPITOPESARESHAREDAMONGALL VIRALENVELOPEPROTEINS4HUS ("S!G DERIVEDPEPTIDEANTIGENSSHOULDBE SUFFICIENTTOELICITCELLULARASWELLASHUMORALIMMUNERESPONSESTARGETING THE VIRAL ENVELOPE ("E!G IS SMALL ENOUGH TO CROSS THE PLACENTA AND IS DISCUSSEDTOINDUCENEONATALTOLERANCE; =3INCE("E!GSHARESMOST OFITSCODINGSEQUENCEWITH("6COREPROTEINS BOTHPROTEINSSHARETHE4

(EPATITIS"VIRUS,ESSONSLEARNEDFROMTHEVIRUSLIFECYCLE



CELLEPITOPES)NADULT 4 CELLRECEPTOR TRANSGENICMICE ("E!GSUPPRESSED THE4 CELL RESPONSE TO ("6 CORE PROTEIN EXPRESSING CELLS INDICATING THAT ("E!GCORECROSS REACTIVE4 CELLSEITHERAREDELETEDORBECOMEANERGISED ;= 3EVERALPOSSIBLEREASONSFORADIMINISHED4 CELLRESPONSEDURINGCHRONIC VIRALHEPATITISAREDISCUSSED4 CELLMODULATIONDUETOORLOCALINDUCTIONOF TOLERANCEINTHELIVER; = SYSTEMICIMMUNOMODULATIONBYTHEINDUCTION OF REGULATORY4 CELLS ANDOR THE EXHAUSTION OF4 CELLS DUE TO ANTIGEN OVER LOAD; = 4AKEN TOGETHER INDUCTION AND MAINTENANCE OF A STRONG AND VIGOROUS 4 CELLRESPONSESEEMSTOBECRUCIALTOACHIEVEVIRUSELIMINATION(OWEVER IT IS IMPORTANT TO NOTICE THAT A CYTOTOXIC4 CELL RESPONSE IS THOUGHT TO BE RESPONSIBLEFORBOTH VIRALCLEARANCEANDLIVERINJURYDURING("6INFECTION ; =

!NTIVIRALLYACTIVECYOKINES #YTOKINESARERELEASEDBYCELLSOFTHEIMMUNESYSTEM BUTALSOBYPARENCHY MALCELLS4HEIRMAINROLEISTOMEDIATEIMMUNERESPONSES BUTSOMEHAVE BEEN PROVEN TO AFFECT ("6 REPLICATION IN HEPATOCYTES TYPE ) AND )) )&. TUMOUR NECROSIS FACTOR 4.& _ AND ), 7HEREAS SECRETION OF )&. _` 4.& _ AND ),  MAY BE INDUCED BY RECOGNITION OF MOLECULAR PATTERNS BY MEMBRANEBOUNDORVIRALNUCLEICACIDSBYENDOSOMALORCYTOPLASMICPAT TERNRECOGNITIONRECEPTORSINABROADVARIETYOFCELLTYPES )&. aISRELEASED BYIMMUNECELLS EG 4 CELLS .+ CELLSORMACROPHAGES )&. _ISLONGKNOWNTOELICITANTIVIRALACTIVITYIN("6INFECTION ANDHAS BEENTHEFIRSTAPPROVEDANTIVIRALTREATMENTFORHEPATITIS"!FTERBINDINGTO SPECIFICRECEPTORSONTHESURFACEOFINFECTEDCELLS )&. _`HAVETHEPOTENTIAL TOTRIGGERTHEACTIVATIONOFMULTIPLENONCYTOLYTICINTRACELLULARANTIVIRALPATH WAYSTHAT FOREXAMPLE INTERFEREWITHTRANSLATIONOFVIRAL2.!SORINDUCE THEIRDEGRADATION !DOPTIVELY TRANSFERRED VIRUS SPECIFIC 4 CELLS CAN ABOLISH ("6 GENE EXPRESSIONANDREPLICATIONINTHELIVERWITHOUTKILLINGTHEHEPATOCYTES4HIS ANTIVIRALFUNCTIONWASMEDIATEDBY)&. aAND4.& _SECRETEDBYTHETRANS FERRED4 CELLSORBYANTIGEN NONSPECIFICMACROPHAGESOR.+CELLSACTIVATED FOLLOWING THE4 CELL TRANSFER ;=4HIS SHOWED THAT )&. a AND4.& _ ARE CENTRALPLAYERSINTHENON CYTOPATHICCONTROLOF("6INFECTION )N A SIMILAR MANNER APPLICATION OF ),  TO ("6 TRANSGENIC MICE EITHER PREVENTED THE ASSEMBLY OR TRIGGERED THE DEGRADATION OF THE NUCLEOCAPSID PARTICLES WITHIN WHICH ("6 REPLICATION OCCURS ;= ),  INFLUENCES("6GENEEXPRESSION;=!NTIVIRALCYTOKINESMAYTHUSACTI VATE INDEPENDENT VIROCIDAL PATHWAYS INFLUENCING VIRAL GENE EXPRESSION ORELIMINATING("6NUCLEOCAPSIDPARTICLESANDTHEIRCARGOOFREPLICATING VIRALGENOMES



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(EPATITIS"VIRUS,ESSONSLEARNEDFROMTHEVIRUSLIFECYCLE



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TARGETEDTHELIVER WASTAKENUPINTOHEPATOCYTESANDINDUCEDAREDUCTION OF("6SECRETIONINVIVO -ORE RECENT STUDIES AIMED AT DECIPHERING THE MECHANISM OF ACTION OF DIHYDROARYLPYRIMIDINES4HEYINDICATETHAT"AY ACTSINACONCENTRA TION DEPENDENT MANNER IN A DUAL MODE BY ACCELERATING AND MISDIRECTING CAPSID ASSEMBLY ; = 2ECENTLY A WHOLE SET OF DIHYDROARYLPYRIMIDINE DERIVATIVESWITHINCREASEDACTIVITIESHAVEBEENDEVELOPEDANDAREPRESENTLY CHARACTERISED WITH REGARD TO THEIR BIOAVAILABILITY GENOTYPE SPECIFICITY OF ACTION TOXICITYANDINVIVOACTIVITY5RBAN UNPUBLISHEDRESULTS 0RESENTLY WELACKDETAILEDSTRUCTURALINFORMATIONONTHEEXACTBINDINGSITES OF"AY  ORITSDERIVATIVESTOTHE("6COREPROTEIN3TRUCTURALINFORMATION WOULDALLOWESTIMATIONOFTHEPROBABILITYOFVIRALESCAPEMUTANTS WHICHMAY EVOLVEUNDERSELECTIONPRESSURE&URTHERMORE INVIVOAPPLICATIONREQUIRES INDUCTION OF CORE PROTEIN DEGRADATION IN ORDER TO PREVENT ITS INTRACELLULAR ACCUMULATION )RRESPECTIVE OF THIS LACK OF KNOWLEDGE DIHYDROARYLPYRIMI DINES REPRESENT A HIGHLY INTERESTING GROUP OF NEW MOLECULES FOR FURTHER CLINICALDEVELOPMENTS )NTERESTINGLY THEANTIVIRALACTIVITYOFHEMEOXYGENASE(/  TARGETS THE SAME STEP IN THE VIRAL CYCLE n CAPSID ASSEMBLY (/  IS A METABOLIC ENZYMECATALYSINGTHEINITIALANDRATE LIMITINGSTEPINTHEOXIDATIVEDEGRADA TIONOFHEME)NADDITION (/ HASIMMUNOMODULATORYPROPERTIESAND EG PREVENTSAPOPTOTICLIVERDAMAGEINIMMUNE MEDIATEDHEPATITISINMICE;= )THASRECENTLYBEENSHOWNTOAMELIORATE("6 ASSOCIATEDLIVERDAMAGEIN MOUSEMODELSOFACUTEANDCHRONICHEPATITIS";=&URTHERMORE ITSHOWED APROFOUNDANTIVIRALACTIVITYREPRESSING("6REPLICATIONATAPOSTTRANSCRIP TIONALSTEP)NTERESTINGLY INDUCTIONOF(/ INHEPATOCYTESREDUCEDTHESTA BILITYOFTHE("6COREPROTEINLEADINGTOAREDUCTIONOFCAPSIDSCONTAINING VIRALREPLICATIVEINTERMEDIATES ANDnASACONSEQUENCEnBLOCKEDTHEREFILLOF NUCLEARCCC$.!;=4HUS INDUCTIONOF(/ MIGHTBEANINTERESTINGNOVEL THERAPEUTICOPTIONFORINFLAMMATORYFLARESOFHEPATITIS"

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(EPATITIS"VIRUS,ESSONSLEARNEDFROMTHEVIRUSLIFECYCLE



!CKNOWLEDGMENT 7E THANK (EINZ 3CHALLER FOR LAYING THE FUNDAMENT OF OUR SCIENTIFIC WORK AND FOR TEACHING US IMPORTANT INSIGHT INTO THE MOLECULAR BIOLOGY OF ("6 ASWELLASITSVIRUS HOSTANDVIRUS CELLINTERACTION7EWILLREMEMBERMANY FRUITFULBUTSOMETIMESCHALLENGINGDISCUSSIONS WHICHHELPEDTOSHARPENOUR VIEW(EINZ3CHALLERALWAYSENCOURAGEDUSTOTHINKANDWORKINDEPENDENTLY FOLLOWINGHIGHSCIENTIFICSTANDARDS3TEPHEN5RBANISPARTICULARLYINDEBTED TOTHE(EINZAND#HICA3CHALLERFOUNDATIONFORSUPPORTINGHIMWITHASHORT TERM FELLOWSHIP7ITHOUT THIS HELP ADMINISTRATIVE REGULATIONS WOULD HAVE PREVAILEDTHEFURTHERPROGRESSOFHISSCIENTIFICWORK7EAREALSOGRATEFULTO #AROLINE'ËHLERFORTHEILLUSTRATION

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(EIDELBERG 'ERMANY $IVISIONOF'ASTROENTEROLOGYAND(EPATOLOGY #ENTRE(OSPITALIER5NIVERSITAIRE6AUDOIS

5NIVERSITYOF,AUSANNE ,AUSANNE 3WITZERLAND

!BSTRACT #HRONIC LIVER DISEASE CAUSED BY INFECTION WITH THE HEPATITIS # VIRUS (#6 IS AN IMPORTANT MEDICAL PROBLEM !LTHOUGH PRIMARY INFECTION USUALLY IS MILD AND OFTEN ASYMPTOMATIC IN THE VAST MAJORITY OF CASES (#6 ESTABLISHES PERSISTENCE THAT IN THE COURSEOFONEORSEVERALDECADESMAYRESULTINCHRONICLIVERDISEASESINCLUDINGLIVERCIR RHOSISANDHEPATOCELLULARCARCINOMA4HERAPEUTICOPTIONSARELIMITEDANDAVACCINETO PREVENT(#6INFECTIONISNOTINSIGHT$IAGNOSTICTESTSTODETECT(#6 CONTAININGBLOOD PRODUCTSHAVEBECOMEAVAILABLEAFTERTHEFIRSTMOLECULARCLONINGOFTHEVIRALGENOME 4HISACHIEVEMENTALSOOPENEDTHEFIELDFORSTUDIESOFTHEVIRALREPLICATIONCYCLEASWELL ASTHEDEVELOPMENTOFSELECTIVEANTIVIRALDRUGS(#6ISAHEPATOTROPICFLAVIVIRUSWHICH HASSEVERALREMARKABLEPROPERTIES!MONGTHESEARETHEPOTENTINHIBITIONOFTHEINDUC TIONPHASEOFTHEINNATEANTIVIRALRESPONSE THEHIGHGENOMICPLASTICITYANDTHEUNUSUAL STRATEGYOFVIRUSPARTICLEASSEMBLYTHATOCCURSINCLOSEASSOCIATIONWITHLIPIDDROPLETS ANDTHEVERY LOW DENSITYLIPOPROTEINPRODUCTIONPATHWAY4HISCHAPTERWILLBRIEFLYSUM MARISESOMEOLDANDNEWASPECTSOFCHRONICHEPATITIS#ANDOFTHEPATHOGENRESPONSIBLE FORTHISDISEASE

)NTRODUCTION (EPATITIS # VIRUS (#6 IS A MAJOR CAUSE OF CHRONIC HEPATITIS LIVER CIR RHOSIS AND HEPATOCELLULAR CARCINOMA (## WORLDWIDE %ND STAGE LIVER DISEASE DUE TO CHRONIC HEPATITIS # IS NOW THE LEADING INDICATION FOR LIVER TRANSPLANTATION!PROTECTIVEVACCINEISNOTAVAILABLEYETANDTHERAPEUTIC OPTIONS ARE STILL LIMITED !S A CONSEQUENCE THE NUMBER OF PATIENTS PRE SENTINGWITHLONG TERMSEQUELAEOFCHRONICHEPATITIS# INCLUDING(## IS EXPECTEDTOFURTHERINCREASEFORTHENEXTTWODECADESEVENIFTHEINCIDENCE OFNEWCASESHASDIMINISHEDSINCETHEINTRODUCTIONOFANTI (#6SCREENING OFBLOODANDBLOODPRODUCTS; ='IVENTHISSCENARIO THEREISANURGENT NEEDTODEVELOPMOREEFFECTIVEANDBETTERTOLERATEDTHERAPIESFORCHRONIC HEPATITIS#



2ALF"ARTENSCHLAGERETAL

%PIDEMIOLOGY )TISESTIMATEDTHATnMILLIONPEOPLEWORLDWIDEAREINFECTEDWITH(#6 ;=4HEVIRUSISPARENTERALLYTRANSMITTED7ITHTHEINTRODUCTIONOFANTI (#6 SCREENINGOFBLOODANDBLOODPRODUCTSIN NEWCASESOFPOSTTRANSFUSION HEPATITIS # HAVE VIRTUALLY DISAPPEARED )NDEED OVER THE LAST  YEARS THE RISKOFPOSTTRANSFUSIONHEPATITIS#COULDBEREDUCEDFROMABOUTPER BLOODUNITSTRANSFUSEDTOPER  n  ;=5NFORTUNATELY THE LACK OF SYSTEMATIC SCREENING OF BLOOD DONORS CONTINUES TO RESULT IN (#6 TRANSMISSION IN COUNTRIES WITH DEVELOPING OR TRANSITIONAL ECONOMIES )N THESECOUNTRIES LARGE SCALEIMMUNISATIONANDPARENTERALTHERAPYPROGRAMS EG FORTHETREATMENTOFSCHISTOSOMIASISIN%GYPTORLEISHMANIASISIN)NDIA ASWELLASSURGICALANDDENTALPROCEDURESWITHINADEQUATELYSTERILISEDEQUIP MENTHAVEALSOBEENIMPORTANTROUTESOFTRANSMISSION; =)NTHE7ESTERN WORLD INTRAVENOUS DRUG USE IS NOW THE MAJOR IDENTIFIABLE MODE OF (#6 TRANSMISSION;=)NADDITION (#6TRANSMISSIONHASBEENDESCRIBEDINTHE NOSOCOMIALSETTING;n=/CCUPATIONALNEEDLESTICKINJURIESFROMANTI (#6 POSITIVE SOURCES RESULT IN SEROCONVERSION IN ON AVERAGE  OF RECIPIENTS )NTRANASALCOCAINEUSEHASBEENIDENTIFIEDASAPOSSIBLEMODEOFTRANSMIS SION @STRAW SHARING ;= 3EXUAL TRANSMISSION IS RARE AND CORRELATES WITH HIGH RISKSEXUALPRACTICES4HERISKOFPERINATALTRANSMISSIONISPROBABLYLESS THAN  UNLESS THE MOTHER IS CO INFECTED WITH ()6 ;= )NTRIGUINGLY IN CLINICALPRACTICENOEPIDEMIOLOGICRISKFACTORCANBEIDENTIFIEDINUPTOONE THIRDOFPATIENTSWITHHEPATITIS#@SPORADICHEPATITIS# 

.ATURALHISTORY !FTERANINCUBATIONPERIODOFnWEEKS(#6INFECTIONISUSUALLYFOLLOWED BY A CLINICALLY INAPPARENT HEPATITIS ;= /NLY ABOUT  OF PATIENTS ARE SYMPTOMATIC &ULMINANT HEPATITIS # IS VERY UNCOMMON /NE OF THE MOST IMPORTANTCLINICALFEATURESOFHEPATITIS#ISITSPROGRESSIONTOCHRONICITYIN n&IG 4YPICALLY PATIENTSWITHCHRONICHEPATITIS#HAVEFEW IFANY SYMPTOMS AND THESE ARE USUALLY NONSPECIFIC INTERMITTENT AND MILD 4HE MOSTCOMMONSYMPTOMISFATIGUE 4HENATURALHISTORYOFCHRONICHEPATITIS#HASBEENANALYSEDINSEVERAL RETRO AND PROSPECTIVE STUDIES ; =7HILE NO INCREASED MORTALITY WAS FOUNDINTHERETROSPECTIVE6ETERANS!DMINISTRATIONSTUDY;= OTHERSTUD IESINDICATEDTHATCHRONICHEPATITIS#FREQUENTLYPROGRESSESTOCIRRHOSISAND (##;=3TUDIESWITHAFOLLOW UPOFUPTOYEARSPERFORMEDINCOHORTS OFWOMENINFECTEDATAYOUNGAGEVIACONTAMINATEDANTI $IMMUNOGLOBULIN HAVESHOWNABENIGNCOURSE; ="YCONTRAST ARECENTREPORTDESCRIB INGACOHORTOFMALEPLASMADONORSINFECTEDINTHESREVEALEDAPOOR OUTCOME WITHONETHIRDOFPATIENTSHAVINGADVANCEDLIVERDISEASEAND HAVINGDEVELOPED(##OREND STAGELIVERDISEASEAFTERAFOLLOW UPOFMORE

Chronic hepatitis C: Portrait of a silent epidemic and the etiologic agent

97

Figure 1. Natural history and management of hepatitis C. Comprehensive management of hepatitis C involves not only antiviral therapy but also preventive measures, liver transplantation (LT) for patients with end-stage liver disease, surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis, and the control of cofactors of disease progression, including, among others, alcohol, hepatitis B virus (HBV) or other coinfections, and overweight.

than 30 years [19]. Factors associated with more frequent and rapid progression to cirrhosis are higher age at the time of infection, male sex, alcohol consumption, coinfections with HBV or HIV, nonalcoholic fatty liver disease (NAFLD), hepatic iron overload, smoking and immunosuppression. Comprehensive management of chronic hepatitis C takes these factors into consideration and aims at improving the ones that can be modified. Once cirrhosis is established, the rate of HCC development is 1–6% per year. HCV infection is responsible for a substantial proportion of the increase in HCC incidence and mortality recently observed in most Western countries [20]. Although experimental evidence raises the possibility that HCV might operate through direct pathways in promoting malignant transformation of hepatocytes, it is generally believed that HCC associated with chronic hepatitis C develops through a general pathway of increased liver cell turnover, induced by chronic liver injury and regeneration, facilitating the development and manifestation of multiple and stepwise genetic alterations [21].



2ALF"ARTENSCHLAGERETAL

(#6GENOMEORGANISATIONANDPOLYPROTEINPROCESSING (#6HASBEENCLASSIFIEDASAMEMBEROFTHEGENUS(EPACIVIRUSTHATTOGETH ER WITH THE GENERA 0ESTIVIRUS AND &LAVIVIRUS AND THE AS OF YET UNASSIGNED SPECIES'"VIRUS! '"VIRUS" AND'"VIRUS#HEPATITIS'VIRUSBELONGS TOTHEFAMILY&LAVIVIRIDAE;=(#6GENOMESCANBEGROUPEDINTOATLEAST SIX GENOTYPES THAT DIFFER IN THEIR NUCLEOTIDE SEQUENCE BY n ;n= &URTHERMORE WITHIN AN (#6 GENOTYPE SEVERAL SUBTYPES CAN BE DEFINED THATDIFFERINTHEIRNUCLEOTIDESEQUENCESBYn4HEVARIABILITYOF(#6 GENOMES IS DUE TO THE HIGH ERROR RATE OF THE VIRAL 2.! DEPENDENT 2.! POLYMERASE2D2P WHICHHASBEENCALCULATEDTOBEINTHERANGEOFABOUT n;= 4HEGENOMEOF(#6ISASINGLE STRANDED2.!OFPOSITIVEPOLARITYTHAT HASALENGTHOFAPPROXIMATELYKB&IG! 4HEGENOMEENCODESALARGE POLYPROTEIN OF ABOUT   AMINO ACIDS THAT IS EXPRESSED VIA AN INTERNAL RIBOSOME ENTRY SITE )2%3 FORMED BY DOMAINS )) TO )6 IN THE  NON TRANSLATED REGION .42 &IG "  4HE  .42 HAS A TRIPARTITE STRUCTURE COMPOSEDOFANABOUTNT LONGVARIABLEREGIONDOWNSTREAMOFTHE(#6 CODING REGION A POLY 55# TRACT OF HETEROGENEOUS LENGTH AND A HIGHLY CONSERVED  NT SEQUENCE NAMED 8 TAIL &IG "  "OTH DOMAINS ) AND )) IN THE  .42 AS WELL AS THE 8 TAIL IN THE  .42 ARE ESSENTIAL FOR 2.! REPLICATION!NEXTRACIS ACTING2.!ELEMENT#2% HASBEENIDENTIFIEDIN THE TERMINALCODINGREGIONOF.3";=&IG" 4HIS#2%DESIGNATED "3, ISREQUIREDFOR2.!REPLICATIONTHROUGHA2.!n2.!INTERACTION WITHASUB REGIONDESIGNATEDAS3,INTHE8 TAIL;= !SFORTHEOTHERMEMBERSOFTHEFLAVIVIRUSFAMILY THELARGEPOLYPROTEIN ENCODEDBYTHE(#6GENOMEISPROCESSEDBYCELLULARANDVIRALPROTEASES TOGENERATEATLEASTVIRALPROTEINS;n=&IG# THATWILLBEDESCRIBED INBRIEF 4HECOREPROTEINRESIDESATTHEVERY. TERMINUSOFTHEPOLYPROTEINAND IS RELEASED FROM THE PRECURSOR BY TWO CLEAVAGES 4HE FIRST ONE SEPARATES CORE FROM % BY SIGNAL PEPTIDASE AND THE SECOND REMOVES THE % SIGNAL PEPTIDEBYSIGNALPEPTIDEPEPTIDASE RELEASINGMATURECOREWITHANAPPARENT MOLECULAR WEIGHT OF ABOUT  K$A ; =4HE CORE PROTEIN IS THE MAJOR CONSTITUENT OF THE NUCLEOCAPSID THAT MAY FORM BY SELF ASSEMBLY ASSUMED TO BE TRIGGERED BY INTERACTION WITH STRUCTURED 2.! ; = )NTERESTINGLY INTRANSFECTEDANDINFECTEDCELLSCORELOCALISESTOLIPIDDROPLETSANDRECENT DATASUGGESTTHATTHESEDROPLETSPLAYAVERYIMPORTANTROLEINVIRUSPARTICLE ASSEMBLY; = %AND%AREHEAVILYGLYCOSYLATEDTYPE)TRANSMEMBRANEPROTEINS;= WITH AN . TERMINAL ECTODOMAIN AND SHORT # TERMINAL HYDROPHOBIC TRANS MEMBRANE DOMAINS 4HE (#6 ENVELOPE GLYCOPROTEINS ASSEMBLE AS NON COVALENTHETERODIMERS;=WITHTHEGLYCANSPLAYINGANIMPORTANTROLEFOR VIRUSINFECTIVITY;=4WOHYPERVARIABLEREGIONS(62S HAVEBEENIDENTI FIED IN % WITH (62 RESIDING IN THE . TERMINAL  AMINO ACID RESIDUES

#HRONICHEPATITIS#0ORTRAITOFASILENTEPIDEMICANDTHEETIOLOGICAGENT



&IGURE/RGANISATIONOFTHE(#6GENOME ESSENTIALCIS ACTING2.!ELEMENTSANDFUNCTIONS OFVIRALPROTEINS! 3TRUCTUREOFTHE(#6GENOME#LEAVAGESITESANDINVOLVEDPROTEASESARE INDICATEDBYARROWS" 2.!ELEMENTSINTHEVIRALGENOME4HE.42WITHITSDOMAINSIS SHOWNINTHELEFTBOX THE#2%INTHE.3"CODINGREGIONINTHEMIDDLEBOXANDTHE.42 THATISCOMPOSEDOFTHEVARIABLEREGIONVR THEPOLY55# TRACTANDTHETERMINAL8 TAIL IS SHOWN IN THE RIGHT BOX # 0OLYPROTEIN CLEAVAGE PRODUCTS AND THEIR FUNCTIONS IN THE VIRAL REPLICATIONCYCLE.OFUNCTIONSCOULDBEASCRIBEDTOTHE& PROTEIN

;=!LTHOUGHTHESEQUENCEVARIABILITYOF(62ISHIGH THECHEMICO PHYSI CALPROPERTIESOFTHEAMINOACIDRESIDUESATEACHPOSITIONANDTHECONFOR MATIONOF(62ITSELFAREHIGHLYCONSERVEDAMONGTHEDIFFERENTGENOTYPES INDICATINGANIMPORTANTROLEOF(62DURINGVIRUSADSORPTIONANDENTRY; ="ASEDONRECENTCOMPARISONOFINTER ANDINTRA HOST%SEQUENCES DERIVED FROM  SUBJECTS INFECTED WITH (#6 A NEW (62 WAS IDENTIFIED TERMED(62;= 4HE SMALL POLYPEPTIDE P IS COMPOSED OF TWO TRANSMEMBRANE REGIONS CONNECTED BY A SHORT CYTOPLASMIC LOOP ; =7HEN EXPRESSED IN A HET EROLOGOUS SYSTEM P LOCALISED TO THE %2 AND MITOCHONDRIAL MEMBRANES ;n= 0 APPEARS TO FORM AN ION CHANNEL ;= PRESUMABLY ESSENTIAL FOR INFECTIVITY IN VIVO ;= BUT DISPENSABLE FOR 2.! REPLICATION ; =6ERY RECENTLY ITWASSHOWNTHATPISESSENTIALFOREFFICIENTASSEMBLYANDRELEASE OFINFECTIOUSVIRIONSANDPPROMOTESVIRUSPARTICLEPRODUCTIONINAGENO TYPE SPECIFICMANNER;=6IRUSINFECTIVITY HOWEVER ISLARGELYINDEPENDENT OFP;=



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4HEINTEGRALMEMBRANEPROTEIN.3ISDISPENSABLEFOR2.!REPLICATION ; = BUTITISESSENTIALFORVIRUSPRODUCTIONINCELLCULTUREANDINFECTIVITY IN VIVO ; = .3 CONTAINS AN . TERMINAL TRANSMEMBRANE DOMAIN AND A # TERMINAL CYSTEINE PROTEASE DOMAIN WITH (IS  'LU  AND #YS  FORMINGTHEACTIVESITE;n=%NZYMATICALLYACTIVE.3ISADIMERWITH COMPOSITEACTIVESITES;= .3 IS A MULTIFUNCTIONAL PROTEIN CONTAINING A SERINE PROTEASE LOCATED IN THE . TERMINAL ONE THIRD AND AN 2.! HELICASE.40ASE LOCATED IN THE # TERMINALTWO THIRDSOFTHEPROTEIN4HESEENZYMATICACTIVITIESHAVEBEEN WELLCHARACTERISED ANDHIGH RESOLUTIONSTRUCTURESHAVEBEENSOLVED;n= &ULL .3 PROTEASE ACTIVITY REQUIRES ACTIVATION BY .3! THAT INTERCALATES INTO THE .3 . TERMINAL PROTEASE DOMAIN )N ADDITION AN . TERMINAL TRANSMEMBRANESEGMENTIN.3!TETHERSTHE.3 !ENZYMECOMPLEXTO INTRACELLULAR MEMBRANES ;= 4HE .3 ! SERINE PROTEASE IS RESPONSIBLE FORPOLYPROTEINCLEAVAGEINTHEREGION# TERMINALOF.3 ANDTHISACTIVITYIS ESSENTIALFORTHEGENERATIONOFTHEVIRALREPLICATIONCOMPLEX4HESEPROPER TIESMAKE.3ANIDEALTARGETFORANTIVIRALTHERAPY 4HE .3 HELICASE IS A MEMBER OF THE SUPERFAMILY  $%X($ BOX HELICASES ;= WHICH ARE CAPABLE OF UNWINDING DOUBLE STRANDED 2.! OR OF SINGLE STRANDED 2.! REGIONS WITH EXTENSIVE SECONDARY STRUCTURE IN AN !40 DEPENDENTMANNER4HEHELICASEACTIVITYMAYBEINVOLVEDININITIATION OF2.!REPLICATION CONTRIBUTETOTHEPROCESSIVITYOFTHEREPLICASECOMPLEX ANDMAYBEINVOLVEDINTHEDISSOCIATIONOFTHEREPLICATIVEFORMINTOPOSITIVE ANDNEGATIVE STRAND(#62.! .3"ISAHIGHLYHYDROPHOBICNONSTRUCTURALPROTEININDUCINGMEMBRA NOUSVESICLESTHATSERVEASASCAFFOLDFORTHEASSEMBLYOFTHE(#6REPLICA TIONCOMPLEX;n=.3"APPEARSTOBEPALMITOYLATEDATTWO# TERMINAL CYSTEINERESIDUES-OREOVER .3"CANOLIGOMERISE WHICHMAYCONTRIBUTE TOTHEINDUCTIONOFMEMBRANECURVATURE;= .3! IS AN 2.! BINDING PROTEIN REQUIRED BOTH FOR 2.! REPLICATION ANDFORVIRUSPARTICLEASSEMBLY)TISCOMPOSEDOFAN. TERMINALAMPHIPA THIC ALPHA HELIX SERVING AS A MEMBRANE ANCHOR ; = AND THREE DISTINCT DOMAINS THAT ARE SEPARATED BY TWO TRYPSIN SENSITIVE LOW COMPLEXITY SEQUENCES $OMAIN ) APPEARS TO BE INVOLVED IN 2.! BINDING DOMAIN )) CONTRIBUTESTO2.!REPLICATIONANDPARTICLEASSEMBLYDOMAIN)))ISLARGELY DISPENSABLEFOR2.!REPLICATIONANDISPRIMARILYREQUIREDFORASSEMBLY; =.3!ISEXPRESSEDASABASALLYPHOSPHORYLATEDANDAHYPERPHOSPHORY LATEDFORMPANDP RESPECTIVELY 0HOSPHORYLATIONISMEDIATED ATLEAST INPART BYCASEINKINASE)ALPHA; =)NTERESTINGLY PARTIALINHIBITIONOF .3!HYPERPHOSPHORYLATIONENHANCES2.!REPLICATION ARGUINGTHATREPLI CASEACTIVITYMAYBEREGULATEDBYTHEPHOSPHORYLATIONSTATUSOF.3!;= 4HEKEYENZYMERESPONSIBLEFOR2.!AMPLIFICATIONISTHE.3"2D2P ;=4HISVIRALENZYMEHASBEENEXTENSIVELYSTUDIED ANDSEVERALHIGH RESO LUTION8 RAYCRYSTALSTRUCTURESHAVEBEENDESCRIBED; =.3"HASTHE CLASSICAL FINGER PALM AND THUMB SUBDOMAINS WITH THE SPECIAL FEATURE THAT

#HRONICHEPATITIS#0ORTRAITOFASILENTEPIDEMICANDTHEETIOLOGICAGENT



THEFINGERANDTHUMBSUBDOMAINSHAVEEXTENSIVEINTERACTIONS RESULTINGIN ACOMPLETELYENCLOSEDACTIVESITE2D2PACTIVITYSEEMSTOBEMODULATEDBY INTERACTIONWITHOTHERVIRALPROTEINS.3AND.3! ASWELLASBYCELLULAR FACTORS ESPECIALLYCYCLOPHILINS;=)TISASSUMEDTHATTHEANTIVIRALACTIVITY OFCYCLOSPORINEISDUETOASEQUESTRATIONOFCYCLOPHILIN;= )NADDITIONTOTHEPOLYPROTEIN (#6APPEARSTOENCODEASMALLPROTEIN DESIGNATED!2&0ALTERNATIVEREADINGFRAMEPROTEIN OR&FRAMESHIFT OR CORETHATISPRODUCEDBYINTERNALINITIATIONOFTRANSLATIONOFANALTERNATIVE READINGFRAMEORBYRIBOSOMALFRAMESHIFTINGWITHINTHECOREGENE;=4HIS PROTEINISDISPENSABLEFOR2.!REPLICATIONINCELLCULTUREANDINVIVOANDITS ROLEINTHEVIRALREPLICATIONCYCLE IFANY ISLARGELYUNKNOWN;  =

!NATOMYOFTHE(#6PARTICLE 4HEBASICBIOPHYSICALPROPERTIESOFTHE(#6PARTICLEWEREINITIALLYDEDUCED FROM INFECTIVITY STUDIES IN CHIMPANZEES 4HE RESULTS INDICATED THAT (#6 FORMSENVELOPEDPARTICLESWITHANAVERAGEDIAMETEROFABOUTnNM; =4HESEPROPERTIESARESIMILARTOTHEONESOBSERVEDWITH(#6PARTICLES PRODUCED IN CELL CULTURE ;=6ERY RECENTLY A $ RECONSTRUCTION MODEL OF (#6 LIKEPARTICLES PRODUCEDININSECTCELLSWASPROPOSED"YANALOGYTOTHE HIGH RESOLUTIONSTRUCTURESOF$ENGUEVIRUSANDTICK BORNEENCEPHALITISVIRUS ENVELOPE GLYCOPROTEINS (#6 % AND % HETERODIMERS MAY FORM DIMERS THATAREORIENTEDPARALLELTOTHESURFACEOFTHEVIRUSPARTICLE;= (#6 PARTICLES HAVE THE PROPENSITY TO BIND TO DIFFERENT SERUM COMPO NENTS SUCH AS LIPOPROTEINS ;= AND IMMUNOGLOBULINS ;= EXPLAINING THE HETEROGENEITY OF THE PARTICLES IN TERMS OF SIZE DENSITY AND SEDIMENTATION COEFFICIENTS!SSOCIATIONOF(#6PARTICLESWITHIMMUNOGLOBULINSHASBEEN REPORTED ANDTHESECOMPLEXESEXHIBITANINTERMEDIATEDENSITYOFAPPROXI MATELY n GML )N CONTRAST MOST (#6 PARTICLES PRESENT WITHIN SERUMFROMANIMMUNOGLOBULIN DEFICIENTPATIENTBANDEDATADENSITYOFLESS THANGML;=4HISVIRUSCOULDBEIMMUNOPRECIPITATEDWITHANTIBOD IES AGAINST APOLIPOPROTEIN " APO" AND APOLIPOPROTEIN % APO% WHICH ARE COMPONENTS OF LOW DENSITY LIPOPROTEIN ,$, AND VERY LOW DENSITY LIPOPROTEIN 6,$, !DDITIONALLY IT HAS BEEN FOUND THAT BLOCKING6,$, ASSEMBLYREDUCES(#6PRODUCTIONINCULTUREDHEPATOCYTES;=&INALLY IN PATIENTS(#6PARTICLESHAVEBEENDETECTEDASPARTOFVERYLARGELIPOPROTEIN COMPLEXES DESIGNATEDLIPO VIROPARTICLES;=!LLTHESEFINDINGSAREINLINE WITHTHEASSUMPTIONOFACLOSEASSOCIATIONOFCIRCULATING(#6PARTICLESWITH ,$,6,$,4HE ASSUMPTION IS CORROBORATED BY THE DEPENDENCE OF (#6 INFECTIONON,$, RECEPTORAND32 ") WHICHARETHERECEPTORSFOR,$,AND ($, RESPECTIVELY;n= 4HUS FAR WE DO NOT KNOW HOW AND WHEN VIRUS PARTICLES ASSOCIATE WITH LIPOPROTEINCOMPONENTS(OWEVER SINCE(#6ASSEMBLYTAKESPLACEINCLOSE PROXIMITY OF LIPID DROPLETS ; = WHICH SERVE AS A LIPID SOURCE FOR THE



2ALF"ARTENSCHLAGERETAL

ASSEMBLY OF6,$, PARTICLES WE HYPOTHESISE THAT ASSOCIATION OF STRUCTURAL PROTEINSWITHONEORSEVERALCOMPONENTSOFTHE6,$,PATHWAYTAKESPLACE DURINGASSEMBLY-OREOVER (#6MAYEXPLOITTHE6,$,PATHWAYTOASSURE PARTICLESECRETION

(EPATITIS#VIRUSREPLICATIONCYCLE 4HEREPLICATIONCYCLESTARTSWITHVIRUSBINDINGVIATHEENVELOPEGLYCOPROTEIN %%COMPLEXTOITSCOGNATERECEPTORSPRESUMABLYINACONSECUTIVEMANNER REVIEWEDIN;  = &IG 6IRUSPARTICLESMAYBETRAPPEDBYINTERAC TIONWITHHEPARANSULPHATEAND,$,RECEPTOR FOLLOWEDBYBINDINGTO32 ")#URRENTEVIDENCESUGGESTSTHATTHESEINTERACTIONSPRECEDEENGAGEMENT WITH#$ FOLLOWEDBYINTERACTIONWITHCLAUDIN ; =(#6ENTERSBY RECEPTOR MEDIATED ENDOCYTOSIS WHICH REQUIRES PASSAGE THROUGH A LOW P( COMPARTMENT ;= .EVERTHELESS VIRUS PARTICLES ARE RESISTANT TO LOW P( TREATMENT ARGUING THAT DURING INTERACTION WITH ONE OR SEVERAL ENTRY MOL ECULES THE VIRAL GLYCOPROTEINS ACQUIRE A P( SENSITIVE CONFORMATION ;= 5PONLIBERATIONOFTHE2.!GENOMEINTOTHECYTOPLASM TRANSLATIONTAKES PLACE AT THE ROUGH ENDOPLASMIC RETICULUM R%2 WHERE POLYPROTEIN PRO CESSING OCCURS &IG  !FTER OR DURING PROTEOLYTIC CLEAVAGE A MEMBRANE ASSOCIATED REPLICATION COMPLEX FORMS DESIGNATED THE MEMBRANOUS WEB WHICH IS THE SITE OF VIRAL 2.! AMPLIFICATION ; = .EWLY SYNTHESISED POSITIVE STRAND2.!SARECOPIEDFROMNEGATIVE STRAND2.!INTERMEDIATES ANDPOSITIVE STRAND2.!ISEITHERRE USEDFOR2.!TRANSLATION ORSERVESAS TEMPLATEFORNEGATIVE STRAND2.!SYNTHESIS ORISPACKAGEDINTONUCLEOCAP SIDS!SSEMBLYOCCURSINCLOSEPROXIMITYTOLIPIDDROPLETSWHERECOREPROTEIN ACCUMULATES; =4HEVIRALREPLICASEAPPEARSTOBERECRUITED PRESUM ABLYVIACORE TOLIPIDDROPLETSWHERETHEVIRAL2.!GENOMEMAYBETRANS FERREDFROMTHEREPLICASETOTHECOREPROTEIN3INCELIPIDDROPLETSARECLOSELY SURROUNDED BY %2 MEMBRANES THAT MAY CONTAIN THE (#6 GLYCOPROTEINS NUCLEOCAPSIDSFORMINGINCLOSEPROXIMITYTOLIPIDDROPLETSMAYACQUIRETHEIR ENVELOPEVIABUDDINGINTOTHE%2LUMEN4HISPROCESSMAYBECONNECTEDTO 6,$,ASSEMBLY;=AND(#6PARTICLESMAYBERELEASED EVENTUALLYASSOCI ATEDWITHCOMPONENTSOF6,$,S VIATHECONSTITUTIVESECRETORYPATHWAY

%XPERIMENTALSYSTEMS 4HE PROPAGATION OF (#6 IN CULTURED CELLS AS WELL AS THE DEVELOPMENT OF EFFICIENTANIMALMODELSHASBEENACHALLENGINGTASKTHATHASBEENOVERCOME INTHEPASTFEWYEARSBYTHEESTABLISHMENTOFPRODUCTIVECELL BASEDREPLICA TIONSYSTEMSASWELLASSMALLANIMALSYSTEMS)NTHEFOLLOWINGWEWILLPROVIDE ONLYAVERYSHORTOVERVIEWABOUTTHEAVAILABLEMODELSTHEINTERESTEDREADER ISREFERREDTOARECENTREVIEW;=

#HRONICHEPATITIS#0ORTRAITOFASILENTEPIDEMICANDTHEETIOLOGICAGENT



&IGURE3CHEMATICREPRESENTATIONOFTHE(#6REPLICATIONCYCLE!FTERBINDINGTOAPERMISSIVE HOSTCELL (#6ENTERSMOSTLIKELYBYRECEPTOR MEDIATEDENDOCYTOSIS 4HEVIRAL2.!IS LIBERATEDINTOTHECYTOPLASMANDTRANSLATIONOCCURSATTHE%2MEMBRANE 4HEPOLYPROTEIN ISPROCESSEDANDAMEMBRANOUSREPLICATIONCOMPLEX DESIGNATEDTHEMEMBRANOUSWEB-7 ISINDUCED WHEREVIRAL2.!ISAMPLIFIED0OSITIVESTRAND2.!PROGENYISENCAPSIDATED ANDVIRUSPARTICLESMAYBERELEASEDFROMTHECELLBYTHECONSTITUTIVESECRETORYPATHWAY 

!NIMALMODELS 4HUS FAR THE ONLY ANIMAL THAT CAN BE INFECTED RELIABLY WITH (#6 IS THE CHIMPANZEE 0AN TROGLODYTES ;= )N SPITE OF ETHICAL CONCERNS AND HIGH COSTS CHIMPANZEEEXPERIMENTSHAVEPROVIDEDINVALUABLEINFORMATIONSUCH ASTHEFIRSTSUCCESSFULTRANSMISSIONOFTHENON ! NON "HEPATITISAGENTFROM HUMANSERUMTOCHIMPANZEES;n= THEESTABLISHMENTOFAHIGH TITRED SERUMPOOLFROMWHICHTHEFIRST(#6GENOMEWASCLONED;= ORTHEDEM ONSTRATIONOFINFECTIVITYOFMOLECULAR(#6CLONES; = "ECAUSE THE CLINICAL COURSE OF DISEASE IN CHIMPANZEES AND HUMANS IS SIMILAR STUDIES OF EXPERIMENTALLY INFECTED ANIMALS HAVE ALSO SHED LIGHT ONTO THE ROLE OF THE IMMUNE RESPONSE IN CONTROLLING VIRUS INFECTION ;= #OMPARABLE TO THE HUMAN SITUATION A SIGNIFICANT PROPORTION OF INFECTED ANIMALSISUNABLETOCLEARTHEVIRUSANDCONTRACTSAPERSISTENTINFECTIONWITH FLUCTUATINGVIRUSTITRESANDEVENTUALSPORADICOCCURRENCEOFLIVERINFLAMMA TION!LTHOUGHITISNOTYETCLEARHOWTHEVIRUSESCAPESTHEIMMUNERESPONSE AN INCREASING BODY OF EVIDENCE SHOWS THAT A VIGOROUS IMMUNE REACTION CORRELATESPOSITIVELYWITHVIRUSELIMINATIONASWELLASLIVERCELLDAMAGE4HE LATTEROBSERVATIONISINKEEPINGWITHTHENOTIONTHATCHRONICHEPATITIS#IS MAINLYSUSTAINEDBYTHEIMMUNEREACTION



2ALF"ARTENSCHLAGERETAL

!TTEMPTSTOESTABLISHAROBUSTSMALLANIMALMODELTHUSFARAREOFLIM ITED SUCCESS ; = (OWEVER SOME PROGRESS HAS BEEN MADE OF WHICH THEMOSTPROMISINGISBASEDONTHEXENOTRANSPLANTATIONOFPRIMARYHUMAN HEPATOCYTESINTOIMMUNODEFICIENT3#)$ TRANSGENICMICE OVEREXPRESSING THEMURINEUROKINASE TYPEPLASMINOGENACTIVATORU0! INTHELIVER;= 5PON ENGRAFTMENT OF HUMAN HEPATOCYTES EARLY AFTER BIRTH THE ANIMALS DEVELOPCHIMERICLIVERSCOMPOSEDOFMURINEANDHUMANHEPATOCYTES4HESE MICE CAN BE PRODUCTIVELY INFECTED WITH (#6 WITH VIRUS REPLICATION BEING CONFINEDTOTHEHUMANHEPATOCYTES

#ELLCULTURESYSTEMS )NSPITEOFTHEAVAILABILITYOFINFECTIOUSMOLECULARCLONESOF(#6GENOMES THEYCOULDNOTBEPROPAGATEDINCULTUREDCELLS!MAJORBREAKTHROUGHINTHE DEVELOPMENTOFAROBUSTANDRELIABLECELLCULTURESYSTEMHASTHEREFOREBEEN THEREPLICONSYSTEM;=&IG! )NTHISSYSTEM THEREGIONENCODINGCORE TO.3WASREPLACEDBYASELECTABLEMARKERNEOMYCINRESISTANCE EXPRESSED VIATHE(#6)2%3 WHEREASTHE(#6NONSTRUCTURALGENESWEREEXPRESSED VIA A HETEROLOGOUS )2%3 5PON TRANSFECTION OF THE HUMAN HEPATOMA CELL LINE(UH  ALOWNUMBEROFNEOMYCIN RESISTANTCOLONIESWASOBTAINEDTHAT CARRIED HIGH AMOUNTS OF AUTONOMOUSLY REPLICATING (#6 2.! (IGH LEVEL REPLICATION WAS DUE TO THE SELECTION FOR BOTH MORE PERMISSIVE (UH  CELLS ANDREPLICATIONENHANCINGMUTATIONSCELLCULTUREADAPTIVEMUTATIONS ;= /WING TO ITS UNPRECEDENTED LEVEL OF (#6 2.! REPLICATION AND ANTIGEN EXPRESSION THEREPLICONSYSTEMBECAMEAVERYIMPORTANTTOOLTOSTUDYTHE INTRACELLULARSTEPSOFTHEVIRALREPLICATIONCYCLEANDPROVIDEDTHEFIRSTFUNC TIONAL CELL BASED PLATFORM FOR SCREENING OF ANTIVIRAL AGENTS THAT TARGET THE 2.!REPLICATIONPROCESS(OWEVER THISSYSTEMDIDNOTSUPPORTTHEPRODUC TIONOFINFECTIOUSVIRUSPARTICLES;n= WHICHISDUETOTHEADAPTIVEMUTA TIONSTHATINTERFEREWITHVIRUSPARTICLEASSEMBLYANDINFECTIVITYINVIVO;= 4HEFIRSTSYSTEMALLOWINGSTUDIESOFTHE(#6INFECTIONPROCESSWASBASED ON(#6PSEUDOPARTICLES(#6PP ; =4HESEPARTICLESARECOMPOSED OF RETROVIRAL NUCLEOCAPSIDS SURROUNDED BY AN ENVELOPE LIPID BILAYER INTO WHICH AUTHENTIC AND ENTRY COMPETENT % % GLYCOPROTEIN COMPLEXES ARE EMBEDDED&IG" 3INCETHEEARLYSTEPSOFINFECTIONAREORCHESTRATEDBY THE ENVELOPE PROTEINS (#6PPS ARE A VERY VALUABLE SURROGATE SYSTEM TO STUDY(#6INFECTIONANDNEUTRALISATION 0RODUCTION OF INFECTIOUS (#6 PARTICLES IN CELL CULTURE ONLY BECAME POSSIBLE WITH THE AVAILABILITY OF A MOLECULAR CLONE CAPABLE OF HIGH LEVEL REPLICATION IN CULTURED CELLS WITHOUT REQUIREMENT FOR CELL CULTURE ADAPTIVE MUTATIONS4HISCLONEWASISOLATEDFROMA*APANESEPATIENTWITHFULMINANT HEPATITIS HENCE THE ACRONYM *&(  ;= 3UBGENOMIC *&(  REPLICONS ARESEVERALORDERSOFMAGNITUDEMOREEFFICIENTTHANREPLICONSDERIVEDFROM OTHER (#6 MOLECULAR CLONES ; = -OST IMPORTANTLY TRANSFECTION OF

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&IGURE  %XPERIMENTAL MODELS TO STUDY (#6 REPLICATION IN CELL CULTURE ! 3TRUCTURE OF A SUBGENOMIC(#6REPLICONCOMPOSEDOFTHE.42THICKLINE THEGENEENCODINGTHENEO MYCIN PHOSPHOTRANSFERASE NEO THE )2%3 FROM THE ENCEPHALOMYOCARDITIS VIRUS %-#6 THE(#6REPLICASEGENESANDTHE.42" !RCHITECTUREOFA(#6PP)TISCOMPOSEDOFA LIPIDENVELOPECONTAININGAUTHENTIC(#6GLYCOPROTEINCOMPLEXESANDTHECAPSID#! OF()6 CONTAININGARETROVIRALVECTOR2.!WITHANINTEGRATEDREPORTERGENEMOSTOFTENEITHERTHEGFP ORTHELUCIFERASEGENE # 3CHEMATICREPRESENTATIONOFTHE(#6CCCELLCULTURE SYSTEM)N VITROTRANSCRIPTSOFTHE*&( GENOMEGENERATEDBYUSING42.!POLYMERASEARETRANSFECTED INTO (UH  CELLS BY ELECTROPORATION 3UPERNATANTS 3UP HARVESTED FROM THE TRANFECTED CELLS AREUSEDFORINFECTIONOFNAÕVE(UH CELLS)NFECTEDCELLSAREDETECTEDBY(#6ANTIGEN SPECIFIC IMMUNOFLUORESCENCE)& 

THE FULL LENGTH *&(  GENOME INTO (UH  CELLS LEADS TO THE PRODUCTION OF (#6PARTICLESTHATAREINFECTIOUSFORNAIVE(UH CELLS; = FORCHIM PANZEES;=ANDFOR3#)$U0!MICEWITHHUMANLIVERXENOGRAFTS;=&IG # 6IRUSTITRESATTAINEDWITH*&( ARERATHERLOW INTHERANGEOFTO TISSUECULTUREINFECTIVITYDOSE4#)$ PERML;= BUTTHESYSTEMWAS IMPROVEDDRAMATICALLYINSEVERALWAYS&IRST BYTHEIDENTIFICATIONOFHIGHLY



2ALF"ARTENSCHLAGERETAL

PERMISSIVE(UH CELLCLONES;=SECOND BYTHECONSTRUCTIONOFCHIMERIC *&(  GENOMES ; = THIRD BY CELL CULTURE ADAPTATION OF *&(  AND *&( CHIMERASORTHEDEVELOPMENTOFAGENOTYPEAISOLATETHATSUPPORTS VIRUSPRODUCTIONALTHOUGHVIRUSTITRESATTAINEDWITHTHISISOLATEARESTILLVERY LOW;n=!DDITIONALIMPROVEMENTSARETHECONSTRUCTIONOFREPLICATION COMPETENT REPORTER VIRUS GENOMES CARRYING EG THE LUCIFERASE GENE OR A GENEENCODINGAFLUORESCENTREPORTER4HELATTERISAPPLICABLETOSTUDYVIRUS INFECTIONINLIVECELLSASWELLASINTERACTIONSBETWEENVIRUSGENOMES

(#6ANDTHEIMMUNESYSTEM !KEYPLAYERTHATBLOCKSTHEINDUCTIONOFTHEEARLYINNATEANTIVIRALDEFENCE APPEARS TO BE THE .3 ! PROTEASE THAT CAN INTERFERE WITH THE DS2.! INDUCED ACTIVATION OF )&. REGULATORY FACTOR  )2&  ;=7ITHIN A CELL DS2.! IS RECOGNISED BY SEVERAL MOLECULES INCLUDING 4OLL LIKE RECEPTOR  4,2 THE 2.! HELICASES RETINOIC ACID INDUCIBLE GENE ) 2)' ) AND MDAALSOCALLED(ELICARD ;=5PONACTIVATIONBYDS2.!BINDING THESE MOLECULESRECRUITADAPTORPROTEINS WHICHARE42)&ALSOCALLED4)#!-  INCASEOF4,2 AND#ARDIFALSOCALLED)03  -!63OR6)3! INCASEOF 2)' )4HESEADAPTORSTRIGGERASIGNALLINGCASCADERESULTINGINTHETRANSCRIP TIONALACTIVATIONOF)&. `)TWASSHOWNTHATBOTH42)&AND#ARDIFCANBE CLEAVEDBYTHE.3 !PROTEASE;n=4HEBLOCKOFTHISPATHWAYMAY CONTRIBUTETOTHEESTABLISHMENTOFAPERSISTENT(#6INFECTION )NADDITION SEVERALSTUDIESSUGGESTTHAT(#6PROTEINSINTERFEREWITHONE OR SEVERAL STEPS OF THE EFFECTOR PHASE OF THE )&. SYSTEM EG BY BLOCKING *AK3TATSIGNALLINGORINHIBITIONOFINDIVIDUALEFFECTORPROTEINSSUCHAS0+2 ;= (OWEVER IT REMAINS TO BE DETERMINED WHETHER THESE OBSERVATIONS MOSTOFTENMADEINARTIFICIALINVITROORCELL BASEDSYSTEMSALSOOPERATEIN VIVO 4HEADAPTIVEIMMUNITYALSOAPPEARSTOBEUNDERMINEDBY(#6WITHOUT GLOBALLYAFFECTINGIMMUNERESPONSETOOTHERINFECTIOUSAGENTS)TISGENERALLY ACCEPTEDTHATTHEVIGOURANDTHEBREADTHOFTHEIMMUNERESPONSEMOUNTED UPON(#6INFECTIONDETERMINETHEOUTCOMEOFINFECTION;=4HEREFORE A SUCCESSFUL IMMUNE RESPONSE TARGETS MULTIPLE -(# #LASS ) RESTRICTED EPITOPES IN THE (#6 POLYPROTEIN AND INDUCES RATHER LARGE NUMBERS OF (#6 SPECIFIC #$ 4 CELLS )N ADDITION A STRONG #$ 4 CELL RESPONSE IS USUALLYACCOMPANIEDBYA STRONGANDMULTI SPECIFIC#$4 CELLPROLIFERA TIVERESPONSEANDPERMANENTLOSSOFTHISRESPONSEISASTRONGPREDICTORFOR PERSISTENCE2ESOLVEDINFECTIONSUSUALLYLEAVEADURABLEMEMORYRESPONSE LOWERING THE CHANCE OF PERSISTENCE UPON RE INFECTION4HE REASON WHY THE STRONGINITIAL4 CELLRESPONSEISBLUNTEDATLATERSTAGESOF(#6INFECTIONIS NOTUNDERSTOOD/NEPOSSIBILITY HOWEVER ISTHATTHEINTERFERENCEOF(#6 WITH THE INNATE IMMUNE RESPONSE RESULTS IN #$4 CELL IMPAIRMENT EG DUETOTHELACKOFIMPORTANTCYTOKINESREQUIREDFOR4 CELLACTIVATION3INCE

#HRONICHEPATITIS#0ORTRAITOFASILENTEPIDEMICANDTHEETIOLOGICAGENT



4 CELLHELPISIMPORTANTFOR#$4 CELLS THEDEGREEOFHELPERCELLIMPAIR MENTWOULDBEACRITICALDETERMINANTOFVIRUSELIMINATIONORPERSISTENCE4HE EXTENTTOWHICH" CELLRESPONSESCONTRIBUTETOVIRALCLEARANCETHUSFARISNOT KNOWN)TISGENERALLYASSUMEDTHAT4 CELLIMMUNITYISTHEPRIMARYDETERMI NANTINCONTROLLING(#6INFECTION

$IAGNOSISOF(#6INFECTION $IAGNOSISOFHEPATITIS#ISBASEDONSEROLOGICALASSAYS WHICHDETECT(#6 SPECIFICANTIBODIESANTI (#6 ANDONMOLECULARASSAYS WHICHDETECT(#6 2.!;=#URRENTENZYMEIMMUNOASSAYS%)!S AREHIGHLYSENSITIVEAS WELLASSPECIFICANDREPRESENTTHEPRIMARYDIAGNOSTICTOOL(#62.!DETEC TION BY REAL TIME 24 0#2 IS NOW STANDARDISED RELIABLE AND REPRODUCIBLE ANDOFFERSABROADDYNAMICQUANTITATIONRANGE(#6BECOMESPOSITIVEBY 24 0#2 AS EARLY AS n WEEKS AFTER INFECTION AND n WEEKS BEFORE ANTI (#6SEROCONVERSION(#62.!TESTINGISUSEDTOCONFIRMACTIVEINFECTION INANTI (#6 POSITIVEINDIVIDUALSANDTODIAGNOSEACUTEHEPATITIS#ORCHRON ICHEPATITIS#INTHERAREIMMUNOCOMPROMISEDPATIENTSTHATDONOTDEVELOP ANTI (#6ANTIBODIES(OWEVER THEPRINCIPALROLEOF(#62.!TESTINGIS INTHETAILORINGANDMONITORINGOFANTIVIRALTHERAPY$ETERMINATIONOF(#6 GENOTYPEISIMPORTANTFORTHESELECTIONOFTHEOPTIMALANTIVIRALREGIMEN ,IVERBIOPSYALLOWSDETERMININGTHENECRO INFLAMMATORYACTIVITYGRAD ING ANDTHEDEGREEOFFIBROSISSTAGING ASWELLASTORECOGNISEOREXCLUDE COEXISTINGLIVERPATHOLOGYSUCHASALCOHOLICLIVERDISEASE IRONOVERLOADOR .!&,$  ,IVER BIOPSY IS STRONGLY RECOMMENDED BEFORE THE INITIATION OF ANTIVIRALTHERAPY !NUMBEROFNON INVASIVETESTSARECURRENTLYBEINGEXPLOREDTOPREDICT LIVERFIBROSIS; =4HESEAREBASEDONDIFFERENTCOMBINATIONSOFBLOOD TESTS TRANSIENT ELASTOGRAPHY &IBRO3CANš ;= OR MAGNETIC RESONANCE IMAGING;=7HILEPROMISING CURRENTPREDICTIONMETHODSREMAINLIMITED WITHRESPECTTOTHEDIFFERENTIATIONOFINTERMEDIATEFIBROSISSTAGESANDTHUS MAYREPLACELIVERBIOPSYONLYINSELECTEDPATIENTS

#URRENTANDFUTURETHERAPY #URRENT STANDARD THERAPY CONSISTS OF PEGYLATED INTERFERON _ 0%' )&. _ ADMINISTERED ONCE WEEKLY BY SUBCUTANEOUS INJECTION COMBINED WITH RIBAVIRIN WHICHISTAKENORALLYONADAILYBASIS;="OTHDRUGSOPERATE THROUGH INCOMPLETELY UNDERSTOOD LIKELY DIRECT ANTIVIRAL AND IMMUNO MODULATORYMECHANISMS;=3TANDARDTREATMENTDURATIONISWEEKSFOR GENOTYPEANDWEEKSFORGENOTYPESAND#URRENTEFFORTSAREAIMED AT TAILORING DOSES AND TREATMENT DURATION TO THE INDIVIDUAL PATIENT BASED ON BASELINE PARAMETERS EG GENOTYPE VIREMIA FIBROSIS STAGE DEGREE OF



2ALF"ARTENSCHLAGERETAL

STEATOSIS ANDON TREATMENTVIRALKINETICSVIREMIAAT ANDWEEKS ;n= (ENCE THERAPY MAY BE ABBREVIATED IN SELECTED PATIENTS WITH FAVOURABLEBASELINEPARAMETERSANDARAPIDVIROLOGICRESPONSEIE NEGA TIVE(#62.!AFTERWEEKSOFTREATMENT WHILEOTHERSMAYBENEFITFROM PROLONGEDTREATMENT )NGENERAL TREATMENTISCURRENTLYRECOMMENDEDFORPATIENTSWITHCHRONIC HEPATITIS#IE PERSISTENTLY;MONTHS= ELEVATEDAMINOTRANSFERASELEVELS ANDANTI (#6ASWELLAS2.!POSITIVITYINSERUM ANDFINDINGSOFFIBROSIS ANDATLEASTMODERATEDEGREESOFINFLAMMATIONANDNECROSISONLIVERBIOPSY &OROTHERPATIENTS DECISIONSWILLHAVETOBEMADEONANINDIVIDUALBASIS &ACTORS ASSOCIATED WITH A FAVOURABLE TREATMENT RESPONSE ARE INFECTION WITH GENOTYPES  OR  LOW BASELINE VIREMIA AND LOW FIBROSIS STAGE &OR UNKNOWNREASONS !FRICAN!MERICANSRESPONDPOORLYTOCURRENTTREATMENT ; = )N ADDITION OVERWEIGHT HAS BEEN ASSOCIATED WITH POOR TREAT MENT OUTCOMES ;= .OVEL AND VERY PROMISING GENOMIC AND PROTEOMIC APPROACHES ARE AIMED AT PREDICTING TREATMENT OUTCOMES ON AN INDIVIDUAL BASIS; = #ONTRAINDICATIONS TO THERAPY WITH 0%' )&. _ AND RIBAVIRIN INCLUDE DECOMPENSATED LIVER CIRRHOSIS AUTOIMMUNE DISEASES UNCONTROLLED DEPRES SIONORPSYCHOSIS PREGNANCY THELACKOFARELIABLEMETHODOFCONTRACEPTION TERATOGENICITY OF RIBAVIRIN CARDIOPULMONARY DISEASES SEVERE LEUKO OR THROMBOCYTOPENIA AND CONDITIONS THAT IMPAIR COMPLIANCE WITH THERAPY 2IBAVIRIN IS IN PRINCIPLE CONTRAINDICATED IN PATIENTS WITH CREATININE CLEAR ANCEMLMINANDSHOULDBEUSEDONLYWITHVERYCLOSEMONITORINGUNDER THESECIRCUMSTANCES !DVERSEEFFECTSOF0%' )&. _INCLUDE AMONGOTHERS FLU LIKESYMPTOMS FATIGUE LEUKO ANDTHROMBOCYTOPENIA WEIGHTLOSS IRRITABILITYORDEPRESSION THYROID DYSFUNCTION HAIR LOSS RASH SEIZURES AND SLEEP DISTURBANCES 4HE MOSTFREQUENTADVERSEEFFECTOFRIBAVIRINISHAEMOLYTICANAEMIA 0ATIENTS WHO BECOME (#6 2.! NEGATIVE DURING THERAPY AND REMAIN SO FOR MORE THAN  MONTHS AFTER THE END OF TREATMENT HAVE A SUSTAINED VIROLOGIC RESPONSE 362 AND USUALLY REMAIN NEGATIVE 0ATIENTS WHO ARE (#62.!NEGATIVEATTHEENDOFTREATMENT BUTBECOMEPOSITIVEAGAINAT MONTHSOFFOLLOW UPARECLASSIFIEDASRELAPSERS ANDPATIENTSWHODONOT RESPONDTOTREATMENTATALLASNONRESPONDERS'ENOTYPE INFECTEDPATIENTS WHODONOTEXPERIENCEA*LOGREDUCTIONOFVIREMIAATWEEKSEARLY VIROLOGICRESPONSE WILLFAILTOACHIEVEAN362; =4REATMENTSHOULD BEDISCONTINUEDINTHESEPATIENTS 7ITH THE ABOVE TREATMENT n OF GENOTYPE  AND ABOUT  OF GENOTYPE  AND  INFECTED PATIENTS ACHIEVE AN 362 ;n= /VERALL ABOUTOFPATIENTSWITHCHRONICHEPATITIS#CANBECUREDWITHTHECUR RENT TREATMENT &OR THESE PATIENTS ONGOING EFFORTS ARE AIMED AT TAILORING TREATMENTTOTHEINDIVIDUALNEEDSINORDERTOIMPROVETOLERABILITY&ORTHE OTHERPATIENTSANDFORTHEIMPORTANTPROPORTIONOFPATIENTSWHOCANNOTTOL ERATECURRENTTREATMENT NEWTHERAPEUTICSTRATEGIESNEEDTOBEDEVELOPED

#HRONICHEPATITIS#0ORTRAITOFASILENTEPIDEMICANDTHEETIOLOGICAGENT



)N PRINCIPLE EACH STEP OF THE (#6 LIFE CYCLE REPRESENTS A TARGET FOR ANTIVIRAL INTERVENTION ;= 3PECIFIC INHIBITORS OF THE BIOCHEMICALLY AND STRUCTURALLY WELL CHARACTERISED .3 ! SERINE PROTEASE AND .3" 2D2P ARE CURRENTLY BEING DEVELOPED AS ANTIVIRAL AGENTS AND THE FIRST CANDIDATES HAVE ALREADY BEEN EVALUATED IN CLINICAL TRIALS ; = 3ERINE PROTEASE INHIBITORS SEEM PARTICULARLY PROMISING AS THEY NOT ONLY BLOCK VIRAL POLY PROTEIN PROCESSING BUT MAY ALSO REVERSE THE INHIBITION OF INNATE IMMUNE SENSINGBY(#6)NADDITION DRUGSAFFECTINGHOSTFACTORSINVOLVEDIN(#6 REPLICATIONAREBEINGEXPLOREDASANTIVIRALAGENTS4HEGENETICVARIABILITYOF (#6 ALLOWING THE RAPID DEVELOPMENT OF ANTIVIRAL RESISTANCE REPRESENTS A MAJORCHALLENGETOTHECLINICALDEVELOPMENTOFSPECIFICINHIBITORS4HEREFORE COMBINATION THERAPY WILL BE NECESSARY FOR THERAPEUTIC SUCCESS ;=7ITH THE INCREASING NUMBER OF NEW COMPOUNDS TARGETING DIFFERENT STEPS OF THE (#6REPLICATIONCYCLE WECANEXPECTTHATTHENUMBEROFPATIENTSTHATCAN BECUREDWILLINCREASEFURTHER

!CKNOWLEDGEMENTS 7ORK IN THE AUTHORS LABORATORIES WAS SUPPORTED BY GRANTS FROM THE -INISTRYOF3CIENCE 2ESEARCHANDTHE!RTSOF"ADEN 7àRTTEMBERG!Z     THE3ONDERFORSCHUNGSBEREICH4EILPROJEKT! THE $EUTSCHE&ORSCHUNGSGEMEINSCHAFT"A  THE#ELL.ETWORKS#LUSTER OF%XCELLENCE(EIDELBERG THE3WISS.ATIONAL3CIENCE&OUNDATION!  THE3WISS#ANCER,EAGUE/NCOSUISSE/#3    AND THE,EENAARDS&OUNDATION

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#HRONICHEPATITIS#0ORTRAITOFASILENTEPIDEMICANDTHEETIOLOGICAGENT



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(EPATITIS!INFECTION -ANFRED(7OLFFAND!XEL3CHMIDT )NSTITUTEOF-ICROBIOLOGYAND6IROLOGY 0RIVATE5NIVERSITYOF7ITTEN(ERDECKE 3TOCKUMER

3TRASSE 7ITTEN 'ERMANY 0RIVATE5NIVERSITYOF7ITTEN(ERDECKE &ACULTYOF-EDICINE !LFRED (ERRHAUSEN 3TR 

7ITTEN 'ERMANY

!BSTRACT (EPATITIS! IS A UBIQUITOUS DISEASE OF MAN WITH ACUTE SELF LIMITING LIVER INFLAMMATION ANDALOWMORTALITYRATE ALSOKNOWNAS@TRAVELLERSHEPATITIS @HEPATITISEPIDEMICA AND @INFECTIOUSHEPATITIS4HECAUSATIVEINFECTIOUSAGENTISTHEHEPATITIS!VIRUSBELONGINGTO THEFAMILYOFTHE0ICORNAVIRIDAE GENUS(EPATOVIRUS4HEROUTEOFTRANSMISSIONISMAINLY FAECAL ORAL(EPATITIS!ISANACUTEHEPATITISTHATDOESNOTBECOMECHRONICLIKEHEPATITIS " AND # AND IT IS NO RISK FACTOR FOR THE DEVELOPMENT OF HEPATOCELLULAR MALIGNANCIES 4HE SEVERITY OF CLINICAL MANIFESTATION IS OFTEN AGE RELATED WITH PREDOMINANTLY INAPPAR ENTINFECTIONINYOUNGINDIVIDUALSTOMORESEVERECOURSESOFINFECTIONINTHEADULTSAND ELDERLY(EPATITIS!ISMOSTPREDOMINANTINCOUNTRIESWITHPOORHYGIENICCONDITIONSAND ISTHEREFORESOMETIMESATTRIBUTEDAS@TRAVELLERSHEPATITIS0OTENTVACCINESFORPROTECTION ANDDISEASEPREVENTIONAREAVAILABLEANDTHEAMBITIOUSMEDICALAIMnERADICATING(!6 BYAGGRESSIVEVACCINATIONSTRATEGIESnAPPEARSREALISTIC

)NTRODUCTION (EPATITIS ! IS A UBIQUITOUS DISEASE OF MAN WITH ACUTE SELF LIMITING LIVER INFLAMMATION AND A RELATIVELY LOW MORTALITY RATE4HE DISEASE IS PREDOMI NANTLYTRANSMITTEDBYTHEFAECAL ORALROUTEANDINEXTREMELYRARECASESBY BLOODDONATIONFROMAPROBANDWITHAHEPATITIS!INFECTIONWITHVIREMIA 4HE CAUSATIVE INFECTIOUS AGENT IS THE (EPATITIS ! 6IRUS (!6  (!6 IS A MEMBER OF THE PICORNAVIRUS FAMILY 0ICORNAVIRIDAE WHICH CONTAINS THE GENERA !PHTHOVIRUS #ARDIOVIRUS %NTEROVIRUS %RBOVIRUS (EPATOVIRUS +OBUVIRUS 0ARECHOVIRUS 2HINOVIRUS AND 4ESCHOVIRUS ;= )NFECTIONS WITH DIFFERENTVIRUSESBELONGINGTOTHISFAMILYARESPREADINHUMANSANDALOTOF OTHERMAMMALS (!6ISTHEONLYMEMBEROFTHESPECIES(EPATOVIRUSANDHASTHEINTERNA TIONAL6IRUS#ODE; =4HEGENETICVARIABILITYISCOMPARA TIVELY LOW AND RECOGNISED WILD TYPE ISOLATES ARE THE STRAINS (- WILD TYPE ACCESSIONNUMBER- (-#ACCESSIONNUMBER-



-ANFRED(7OLFFAND!XEL3CHMIDT

!'-SIMIANORIGIN ACCESSIONNUMBER$ AND#2/FFURTHER GENOMICSCIENTIFICIMPORTANCEARETHEISOLATES,5 ,9 ,! '"- -"" !(  AND&( ;= (!6ISVIRULENTFORHUMANSANDHIGHERPRIMATES@/LD[email protected]  4HEMAJORTISSUETROPISMISWITHINTHELIVERTHEREISALSOSOMEMINORTISSUE TROPISMFORINTESTINALEPITHELIA!CONSIDERABLYPERSISTENTPRODUCTIVEINFEC TIONOVERAPERIODOFUPTOMONTHSnESPECIALLYOFLIVERCELLSnISCOMMON 4HESPECIALITYOFTHE(!6(EPATOVIRUSWITHINTHE0ICORNAVIRIDAEISTHATTHIS VIRUSSHOWSACOMPARABLYLOWLEVELOF2.!REPLICATIONCOMPAREDTOMOST OFTHEOTHERPICORNAVIRUSES 0REVIOUSLY (!6WASCLASSIFIEDAS%NTEROVIRUSTYPE,ATERITHASBEEN SHOWN BY SEVERAL STUDIES THAT IT CAN BE DISTINGUISHED FROM OTHER PICORNA VIRUSES WITH REGARD TO NUCLEOTIDE AND AMINO ACID SEQUENCES AND GROWTH IN CELL CULTURE4HUS IT IS CLOSELY RELATED TO POLIOVIRUS GENUS %NTEROVIRUS COXSACKIEVIRUS GENUS %NTEROVIRUS AND ECHOVIRUS GENUS 0ARECHOVIRUS WHICHAREOFRELEVANCEFORHUMANINFECTIONS (!6 WAS FIRST DISCOVERED BY IMMUNE ELECTRON MICROSCOPY IN  ;= ANDISOLATEDINCELLCULTUREIN;=4HECHARACTERISATIONOFTHE(!6CAP SIDPROTEINSWASPERFORMEDIN; =ANDTHEGENOMEWASCHARACTERISED ASSINGLE STRANDED2.!IN;=(!6HASONLYONEMAJORSEROTYPE; =ASONLYONENEUTRALISATIONSITEISIMMUNODOMINANT;=4HEREISNOSERO LOGICALCROSS REACTIONBETWEEN(!6ANDOTHERVIRUSESCAUSINGHEPATITIS 4HEVIRIONISKNOWNTOBEVERYSTABLE RESISTANTTOELEVATEDTEMPERATURE AND ACIDIC P( CONDITIONS )T ALSO HAS A HIGH RESISTANCE TO CHEMICALS AND ENVIRONMENTALINFLUENCES)THASBEENFOUNDTOSURVIVEFORDAYSTOMONTHS INEXPERIMENTALLYCONTAMINATEDFRESHWATER SEAWATER WASTEWATER ANDSOILS ASWELLASINLIVEOYSTERANDCREAM FILLEDCOOKIES;= (!6ISANIMPORTANTPATHOGENTHEINFECTIONISACOMMONFORMOFACUTE USUALLY SELF LIMITING VIRAL HEPATITIS IN MANY PARTS OF THE WORLD AND CAUSES WORLDWIDEABOUTMILLIONCASESOFACUTECLINICALHEPATITISEACHYEAR @!CUTE HEPATITIS IS MOST COMMONLY DEFINED AS A HEPATITIS LASTING NO LONGERTHANMONTHS!CHRONICDISEASEMANIFESTATIONASINOTHERFORMSOF INFECTIOUSORNON INFECTIOUSHEPATITISISNOTOBSERVEDINHEPATITIS!)TISNOT ONLYADISEASEIN@DEVELOPINGCOUNTRIESBUTACCOUNTSFORABOUTOFALL CASESOFHEPATITISINTHE@DEVELOPEDWORLD WHEREASMANYCASESHAVETOBE ATTRIBUTEDTOTRAVELLINGACTIVITIESINTOREGIONSWITHHIGHPREVALENCEFOR(!6 INFECTION/UTBREAKSOCCURPERIODICALLYINSEVERALCOUNTRIES4HEINCIDENCE OF HEPATITIS! IS CLOSELY RELATED TO SOCIOECONOMIC DEVELOPMENT4HE MAIN VEHICLESOFTRANSMISSIONAREFAECALLYCONTAMINATEDFOODANDWATER;=

6IRALSTRUCTUREANDREPLICATION (EPATITIS ! VIRUS SHARES THE KEY PROPERTIES OFT THE PICORNAVIRUS FAMILY 4AB 4HE VIRION IS AN ICOSAHEDRAL NUCLEAR CAPSID WITH A DIAMETER FROM

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nNMWITHCUBICSYMMETRYANDCOMPOSEDOF2.!ANDPRO TEIN ;= &IG   4HE CAPSID POSSESSES FOUR MAJOR STRUCTURAL COMPONENTS 60 60 60 60 4HE MOLECULAR WEIGHTS RANGE FROM n K$ 4HE SURFACEPROTEINS60AND60AREMAJORANTIBODY BINDINGSITES4HECAPSID CONTAINSBOTHPRECURSOR60ANDPRODUCT60%ARLYSTUDIESHAVESHOWNTHE EXISTENCEOFAVERYSMALLPROTEINnK$ )TWASNOTPOSSIBLETOIDENTIFYIT AS60BYIMMUNOLOGICREACTIVITYORSEQUENCEANALYSIS)NOTHERPICORNAVI RUSESSUCHASPOLIOVIRUS60ISAPPROXIMATELYK$ANDISMYRISTOYLATEDAT THE. TERMINALGLYCINE)NPOLIOVIRUS60ISFOUNDONTHEINTERIORCAPSIDSUR FACEANDMAYCONTRIBUTETOPARTICLEASSEMBLYANDSTABILITYORTOBINDINGAND ENTRYOFVIRUSINTOCELLS;=60HASNOTBEENCONCLUSIVELYDEMONSTRATED IN(!6PARTICLES)FITEXISTSITISMUCHSMALLERTHANOTHERPICORNAVIRAL60 MOLECULESANDNOTMYRISTOYLATED;= 4HE NUCLEOCAPSID CONTAINS  CAPSOMERES ,IKE OTHER PICORNAVIRUSES (!6HASNOENVELOPE&IG  &IRSTC$.!CLONESHAVEBEENPRODUCEDIN;=ANDFIRSTINFECTIOUS C$.!CLONESOF(!6WERESUCCESSFULLYGENERATEDIN;= MAKINGTHIS VIRUSACCESSIBLETOMOLECULARBIOLOGY4HEVIRIONCONTAINSONECOPYOFLINEAR POSITIVE SENSE SINGLE STRANDED2.!WITHARELATIVELYLOW'#CONTENTOF 4HE (!6 GENOME IS  KB IN SIZE AND CAN BE DIVIDED INTO THREE

124

Manfred H. Wolff and Axel Schmidt

Figure 1. Electron microscopic image of HAV (Hepatitis A virus/strain HM 175); the bar represents 60 nm.

parts: (i) a 5’ non-coding region (NCR) that comprises approximately 10% of the genome, (ii) an open reading frame that encodes all of the viral proteins and (iii) a short NCR [16]. RNA sediments at 33 S and has a buoyant density of 1.33 g/mL [9]. With RNA extracted from cells or transcribed from cloned amplified cDNA cultured cells can be transfected [9, 18]. RNA also has been translated in vitro demonstrating that the viral genome follows the same translation strategy as the monocistronic genomes of the other picornaviruses [19]. The 5’ untranslated region functions as an internal ribosome entry site to which the genome-linked protein VPg is covalently linked. The virus enters the cell by acid-independent receptor-mediated endocytosis. Genomic replication occurs within the cytoplasm, and the corresponding replicase is a virus-encoded 3D RNA-dependent RNA polymerase which generates partially double-stranded replicative intermediate RNA. The egress mechanism after virion assembly within cytoplasmatic membrane vesicles is still unknown and a matter of current research. Although 3–7 genotypes of HAV have been characterised [20, 21], only one major serotype can be defined so that there appears to be no variation detectable by serology in these neutralisation sites.

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126

Manfred H. Wolff and Axel Schmidt

Figure 3. HAV: Cytopathic effect (CPE) in FRhK- 4 cells: typical CPE occurs 7 days post infectionem: A) Control (mock-infected), B) HAV-infected: typical CPEs

depth of 0.9 cm for 1 min) or formalin treatment (3% for 5 min) the virus will be destroyed rapidly [27, 28]. Against chemicals, especially such which are contained in disinfectants, HAV is relatively resistant. Inactivation by glutaraldehyde or peracetic acid (Figs 2c and 2d) is possible in a proper time and concentration, whereas alcohols are not able to decrease the infectivity in a suitable time (Fig. 2b).This is problematic because hand disinfectants usually contain alcohols. In our hands none of the tested commercially available disinfectants showed a log 10 reduction factor which satisfies the requirements of the corresponding German authorities (BGA/DVV; M.H. Wolff, S. Probst, unpublished results), internationally representative as key opinion leaders within this field.

Propagation in cell culture It is still difficult to grow HAV in cell culture. Especially the isolation of wild-type virus from the faeces of a patient often fails. HAV shows a strong tissue tropism. Permissive cell lines are the AGMK, FRhK-4, and BSC-1 cell-line. There are several virus strains which are used for research; the cytopathic HAV variant HM 175 characterised by T. Cromeans et al. (1989) [29] is frequently used for studies. This strain can be propagated in foetal rhesus monkey kidney cells (FRhK-4). On these cells a typical cytopathic effect (CPE) is visible 10–14 days after infection (Fig. 3).

Transmission Transmission of HAV usually occurs by the faecal-oral route either by direct close contact with infected persons or by ingestion of virus-contaminated water or food. In these cases the amount of virus incorporated plays an

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IMPORTANT PART )NFECTED PEOPLE EXCRETE n VIRUS PARTICLES PER GRAM OFSTOOLBUTALREADYANINFECTIONDOSEOFONLYTOVIRUSPARTICLESLEADS TOINFECTION)NSOFAR(!6ISAPOTENTPATHOGENWHICHHASBEENRESPONSIBLE FOR MANY FOOD BORNE OUTBREAKS 4HE FOOD IMPLICATED IN THESE OUTBREAKS MAINLY IS SHELLFISH )NFECTIONS ARE ALSO DESCRIBED AFTER CONSUMPTION OF CONTAMINATED RAW OYSTERS MUSSELS AND CLAMS ;n= %VEN IF THE FOOD IS HEATED INFECTIONS ARE POSSIBLE BECAUSE n AS MENTIONED ABOVE n THE USED TEMPERATUREANDHEATINGTIMEUSUALLYISNOTSUFFICIENTTOINACTIVATETHEVIRUS )NFECTIONSHAVEALSOBEENCAUSEDBYSALADS FRUITS VEGETABLESASWELLASDAIRY PRODUCTS SANDWICHES BAKEDPRODUCTS; =ANDCREAM FILLEDCOOKIES;= "UTTHEREAREALSOSTUDIESDESCRIBINGTHETRANSMISSIONINHOMOSEXUALMEN AND IT IS EVEN ASSERTED THAT HOMOSEXUAL MEN ARE THE MOST IMPORTANT RISK GROUPFORTHETRANSMISSIONOF(!6INFECTION;=%VENTHOUGH(!6ISAN ENTEROVIRUS AND USUALLY TRANSMITTED BY FAECAL ORAL ROUTE THERE ARE SINGLE OBSERVATIONSWHICHSHOWATRANSMISSIONBYBLOODORBLOODPRODUCTS; = SOTHATALSOCASESOFINFECTIONININDIVIDUALSWITHINTRAVENOUSDRUGADDICTION HAVE BEEN REPORTED4HERE IS ALSO A RISK FOR INFECTION FOR PEOPLE WORKING WITHWASTEWATERMANAGEMENT

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7ITTEN 'ERMANY )NSTITUTEOF-ICROBIOLOGYAND6IROLOGY 0RIVATE5NIVERSITYOF7ITTEN(ERDECKE 3TOCKUMER

3TRASSE 7ITTEN 'ERMANY

!BSTRACT (EPATITIS % n FORMERLY CALLED @ENTERICALLY TRANSMITTED NON ! NON " HEPATITIS n IS TRANSMITTED BY THE FAECAL ORAL ROUTE4HE (EPATITIS %6IRUS (%6 IS A POSITIVE SENSE SINGLE STRANDED 2.! VIRUS AND HAS GREAT SIMILARITIES TO THE CALICIVIRUSES6IRUS REPLICA TION APPEARS TO BE LIMITED TO THE HEPATOCYTE4HE DISEASE IS ESPECIALLY ENDEMIC ANDOR EPIDEMICONTHE)NDIANSUB CONTINENT%PIDEMICSAREMOSTLYWATERBORNEINFECTIONS!LSO INOTHER@DEVELOPINGREGIONSOUTBREAKSOF(%6INFECTIONAREOBSERVED)NINDUSTRIALISED COUNTRIESTHISDISEASEONLYPLAYSAMINORROLEINHEPATITISINFECTIONS(%6CAUSESEPIDEM ICS ENDEMICSANDSPORADICCASESOFACUTEHEPATITIS4HEINCUBATIONPERIODFORHEPATITIS% VARIESFROMnWEEKS4HECOURSEOFDISEASEISUSUALLYMILDANDSELF LIMITINGANDRESOLVES WITHINAWEEKSPERIOD&ULMINANTCASESOFINFECTIONARERARE(%6INFECTIONDOESNOT INDUCECHRONICCOURSESOFHEPATITISORLIVERDISEASE)NCLINICALLYAPPARENTCASESOFINFEC TIONJAUNDICE PRURITUS CLAY COLOUREDFAECESANDGENERALISEDLYMPHADENOPATHIAMAYBE OBSERVED&ATALINFECTIONSOFFULMINANTHEPATITIS%ARERARE0REGNANTWOMENAPPEARTOBE EXCEPTIONALLYSUSCEPTIBLETOSEVEREDISEASEFORMS WITHANEXCESSIVEMORTALITYOFINFECTED MOTHERSOFABOUTINTHISGROUP(%6INFECTIONSAPPEARINGLYINDUCEMOSTLYLIFE LONG IMMUNITYTORE INFECTION4ODATETHEREISNOTHERAPYAGAINST(%6INFECTIONAVAILABLE4HE ATTEMPTS IN GENERATING A VACCINE AGAINST (%6 INFECTIONS ARE PROMISING )MPROVING THE SOCIOECONOMICSITUATIONnINCLUDINGHYGIENICCONDITIONSnISTHEMOSTEFFECTIVEMEASURE OFDISEASEPREVENTION

)NTRODUCTION (EPATITIS% FORMERLYCALLED@ENTERICALLYTRANSMITTEDNON !NON "HEPATI TISISTRANSMITTEDBYTHEFAECAL ORALROUTE4HE(EPATITIS%6IRUS(%6 IS A STILL UNASSIGNED GENUS WITH GREAT SIMILARITIES TO THE CALICIVIRUSES4HE MORPHOLOGY OF THE NON ENVELOPED VIRION IS SPHERICAL AND THE GENOME CONSISTS OF A POLYADENYLATED POSITIVE SENSE SINGLE STRANDED LINEAR  SEG MENT 2.! OF AN ABOUT  KB 2EPLICATION OF THE VIRUS APPEARS TO BE LIMITED TO THE HEPATOCYTE!LSO NON HUMAN PRIMATES ARE SUSCEPTIBLE FOR (%6INFECTION4HEDISEASEISESPECIALLYENDEMICANDOREPIDEMICONTHE



!XEL3CHMIDTAND-ANFRED(7OLFF

)NDIAN SUBCONTINENT %PIDEMICS ARE MOSTLY WATERBORNE INFECTIONS !LSO IN OTHER @DEVELOPING REGIONS EG !SIAN 0ACIFIC 2EGION FORMER 3OVIET 5NION -IDDLE%AST NORTHERNWESTERNPARTSOF!FRICA OUTBREAKSOF(%6 INFECTIONAREOBSERVED)NINDUSTRIALISEDCOUNTRIESTHISDISEASEONLYPLAYSA MINORROLEINHEPATITISINFECTIONS4HEPATHOPHYSIOLOGYOF(%6INFECTION ISSTILLPOORLYUNDERSTOOD(%6CAUSESEPIDEMICS ENDEMICSANDSPORADIC CASESOFACUTEHEPATITIS4HEINCUBATIONPERIODFORHEPATITIS%VARIESFROM nWEEKSAVERAGED $URINGACUTEINFECTIONAMOSTLYSHORTVIREMIC PERIODISOBSERVED!PERSISTENTINTESTINALCARRIERSTAGEORPERSISTENTVIRE MIAHASNOTBEENREPORTED4HECOURSEOFDISEASEISUSUALLYMILDANDSELF LIMITINGANDRESOLVESWITHINAWEEKSPERIOD&ULMINANTCASESOFINFECTION ARE RARE (%6 INFECTION DOES NOT INDUCE CHRONIC COURSES OF HEPATITIS OR LIVER DISEASE #LINICALLY APPARENT CASES OF (%6 INFECTION ARE MOST OFTEN SEEN IN YOUNG TO MIDDLE AGED ADULTS n YEARS OLD  #LINICALLY (%6 INFECTION IS INDISTINGUISHABLE FROM THE OTHER FORMS OF VIRAL HEPATITIS )N CLINICALLYAPPARENTCASESOFINFECTIONJAUNDICE PRURITUS CLAY COLOUREDFAE CESANDGENERALISEDLYMPHADENOPATHIAMAYBEOBSERVED&ATALINFECTIONS OFFULMINANTHEPATITIS%ARERARE(%6EXHIBITSITSHIGHESTVIRULENCEWITHIN THETHIRDTRIMESTEROFPREGNANCY0REGNANTWOMENAPPEARTOBEEXCEPTION ALLY SUSCEPTIBLE TO SEVERE DISEASE FORMS WITH AN EXCESSIVE MORTALITY OF INFECTEDMOTHERSOFABOUTREPORTEDINTHISGROUP4HEREISALSOAHIGH FREQUENCYOFCASESOFINTRAUTERINEDEATHSANDABORTIONSINCASEOFMATERNAL INFECTION(%6INFECTIONSAPPEARINGLYINDUCEMOSTLYLIFE LONGIMMUNITYTO RE INFECTION)NCASEOFDIAGNOSTICSSEROLOGICALANDMOLECULARAPPROACHES ARE COMBINED FOR EARLY AND APPROPRIATE RESULTS 5NTIL NOW THERE IS NO THERAPYAGAINST(%6INFECTIONAVAILABLE4HEATTEMPTSINGENERATINGAVAC CINEAGAINST(%6INFECTIONSAREPROMISING)MPROVINGTHESOCIOECONOMIC SITUATION INCLUDING HYGIENIC CONDITIONS IS THE MOST EFFECTIVE MEASURE OF DISEASEPREVENTION

6IROLOGY 4HE (EPATITIS %6IRUS (%6 (%6 LIKE VIRUS IS A NON ENVELOPED VIRUS PARTICLE WITH A DIAMETER OF n NM )TS6IRUS #ODE IS  !CCORDING TO THE )NTERNATIONAL #OMMITTEE ON 4AXONOMY OF 6IRUSES )#46 (%6 IS STILL OFFICIALLY UNASSIGNED (OWEVER THE GENUS IS NAMED @(EPEVIRUS AND THE FAMILY @(EPEVIRIDAE IN CERTAIN DATABASES IE THE .#") TAXONOMY DATABASE 4HE MORPHOLOGY IS SPHERICAL AND THE VIRION STRUCTURE VERY SIMILAR TO THAT OF THE CALICIVIRUSES ;= 4HE SEROLOGICALLY RELATEDSMALLERPARTICLESOFnNMINSIZEAREOFTENFOUNDINFAECESOF PATIENTS WITH ACUTE HEPATITIS % INFECTION AND ARE RECENTLY PRESUMED TO REPRESENTDEGRADEDVIRALPARTICLES -OLECULAR ANALYSIS OF THE (%6 GENOME HAS SHOWN THAT IT IS A POLYAD ENYLATEDPOSITIVE SENSESINGLE STRANDED LINEAR SEGMENT2.!OFANABOUT

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KBWITHSHORT ANDNON CODINGREGIONSWHICHCONTAINTHREESEPARATE OPENREADINGFRAMES/2&S ;=4HE'#CONTENTISnANDTHE BUOYANT DENSITY  GM, RESPECTIVELY4HE REPLICATION STRATEGY OF (%6 ISPOORLYUNDERSTOODUNTILNOW APARTTHATITHASBEENSHOWNTHATTHETRAN SCRIPTASEANDREPLICASEAREVIRUS ENCODED2.! DEPENDENTPOLYMERASES;= 2EPLICATIONOFTHEVIRUSMAYBELIMITEDTOTHEHEPATOCYTE)THASBEENPOSTU LATEDBY2EYESETAL;=THATAFTERTHEVIRUSENTERSTHEHEPATOCYTE THEPOSI TIVE SENSE(%62.!ISTRANSLATEDTOPRODUCETHENON STRUCTURALPROTEINS NEEDEDFORTHEGENERATIONOFNEGATIVE STRANDED2.!@ANTIGENOMIC2.!  4HISNEGATIVE STRANDED2.!MAYTHENSERVEASATEMPLATEFORSYNTHESISOF POSITIVE SENSE2.!ANDSUBGENOMIC2.!S WHICHENCODETHEPRODUCTION OF THE STRUCTURAL PROTEINS IN ORDER TO ENCAPSIDATE THE POSITIVE SENSE 2.! FOR THE ASSEMBLY OF NEW VIRAL PARTICLES )T IS YET UNCLEAR IF THERE MIGHT BE ADDITIONALREPLICATIONWITHINTHEGUT !TYPICALISOLATESWHICHDIFFER FROMTHETYPESTRAINHAVE BEENREPORTED MINORDIFFERENCESINRESISTANCETOINACTIVATION SLIGHTDIFFERENCESINIMMU NOREACTIVITY BUT IT IS GENERALLY ACCEPTED THAT ONLY ONE SEROTYPE OF (%6 HAS BEEN IDENTIFIED UP TO NOW ;= .EVERTHELESS ISOLATES OBTAINED FROM GEOGRAPHICALLY MORE DISTANT REGIONS TEND TO SHOW HIGHER DIFFERENCES IN THEIRAMINOACIDSEQUENCES4HESEOBSERVATIONSSHOWEDTHATTHE2.!POLY MERASE REGION APPARENTLY IS THE MOST CONSERVED REGION WITHIN THE (%6 GENOME4ENDENCIESFORSPONTANEOUSMUTATIONSARERAREANDAHOMOLOGOUS IMMUNITYCANBEPOSTULATEDASSECONDINFECTIONSWITH(%6HAVENOTBEEN REPORTEDSOFAR !LSONON HUMANPRIMATESSUCHAS#YNOMOLGUSMACAQUESANDOWLMON KEYS MARMOSETS !OTUS MONKEYS AND CHIMPANZEES CAN BE EXPERIMENTALLY INFECTED WITH (%6 AND AN ACUTE FORM OF HEPATITIS CAN BE INDUCED WITHIN THESESPECIES;= 4HE PROPAGATION OF THE VIRUS IN CELL CULTURE IS STILL PROBLEMATIC WHICH COMPLICATESVIROLOGICALRESEARCHONTHISINFECTIOUSAGENT2ECENTLYA#HINESE ISOLATEWASREPORTEDTOBESUCCESSFULLYCULTIVATEDINHUMANLUNGCARCINOMA CELLS(UANGETAL ;=UNCONFIRMEDOBSERVATION  (%6SEQUENCESAREACCESSIBLEFORTHESTRAINS@-EXICO- @3!2  - @+  , @53 !& @53 !& @GENOTYPE  !* @(YDERABAD )NDIA !& @4+ !& @FULMINANT HEPATITIS 8 @5IGH  $ @(E"EI - ANDTHE4YPE3TRAIN- 4HEACCESSIONNUMBERSAREGIVEN INBRACKETS

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AND IN 7ONG ET AL REPORTED THE FIRST EVIDENCE FOR THE EXISTENCE OF A @NON ! NON "VIRALAGENTASCAUSATIVEINFECTIOUSAGENT;=)N"ALAYAN ETALPUBLISHEDDEEPERINSIGHTSINTOTHISINFECTIVEAGENTINCLUDINGTHESUC CESSFULEXPERIMENTALTRANSMISSIONOFTHEINFECTIOUSAGENTTONON HUMANPRI MATES;=!FTEREXTENSIVERESEARCHONTHESTRUCTUREOFTHEPARTICLEANDTHE GENOMETHEREAFTER 'OLDSMITHETALDEVELOPEDTHEFIRST%,)3!TESTSYSTEM FORHEPATITIS%DIAGNOSTICS;= THEFUNDAMENTALBASEFORDIAGNOSTICASSESS MENTOFTHEDISEASE

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#LINICS 4HEPATHOLOGYANDPATHOPHYSIOLOGYOF(%6INFECTIONISSTILLPOORLYUNDER STOOD(EPATITIS% ORFORMERLYCALLED@ENTERICALLYTRANSMITTEDNON !NON " HEPATITISISTRANSMITTEDBYTHEFAECAL ORALROUTE(%6HASNOTBEENISOLATED

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FROM FOOD AND NO STANDARDISED METHOD IS CURRENTLY AVAILABLE FOR ROUTINE ANALYSISOFFOODCONCERNING(%6 4HE INCUBATION PERIOD FOR HEPATITIS % VARIES FROM TWO TO NINE WEEKS AND IS ON THE AVERAGE APPROXIMATELY  DAYS!S ASSESSED IN NON HUMAN PRIMATESITISMOSTOBVIOUSTHATTHEVIRUSISSHEDINTHEFAECESAFTERITSPAS SAGEFROMTHELIVERTISSUEINTOTHEBILEANDINTOTHEDUODENUM CONSECUTIVELY $URINGACUTEINFECTIONAMOSTLYSHORTVIREMICPERIODISOBSERVED MOSTLYAT THETIME POINTWHENJAUNDICEBECOMESOBVIOUS)NASTUDYOF.ANDAETAL ;=PROLONGEDPHASESOFVIREMIAWEREREPORTEDINUPTOOFTHECASESOF ACUTE(%6INFECTION/NEPATIENTISREPORTEDWHEREVIREMIABEGANASEARLY ASONEWEEKBEFORETHEONSETOFJAUNDICEANDLASTEDFORAFURTHERMONTHS .EVERTHELESS APERSISTENTINTESTINALCARRIERSTAGEORPERSISTENTVIREMIAHAS NEVERBEENDESCRIBED 4HE COURSE OF DISEASE IS USUALLY MILD AND SELF LIMITING AND RESOLVES WITHINAWEEKPERIOD&ULMINANTCASESOFINFECTIONARERARE(%6INFEC TION DOES NOT INDUCE CHRONIC COURSES OF HEPATITIS OR LIVER DISEASE SUCH AS CIRRHOSISORHEPATICNEOPLASIA#LINICALLYAPPARENTCASESOF(%6INFECTION AREMOSTOFTENSEENINYOUNGTOMIDDLEAGEDADULTSOFnYEARSOLD)N YOUNGER INDIVIDUALS AND CHILDREN INFECTIONS TEND TO BE ANICTERIC4O DATE (%6 INFECTION IS THE MOST COMMON FORM OF CLINICALLY APPARENT SPORADIC VIRALHEPATITISINTHEYOUNGADULTPOPULATIONIN@DEVELOPINGCOUNTRIESWHEN WEFOCUSONTHE@/LD7ORLD&ROMTHECLINICALPERSPECTIVE(%6INFECTION IS INDISTINGUISHABLE FROM THE OTHER FORMS OF VIRAL HEPATITIS )N CLINICALLY APPARENTCASESOFINFECTIONJAUNDICEMOSTLYLASTSFROMONEUPTOWEEKS !LSO PRURITUS CLAY COLOURED FAECES AND GENERALISED LYMPHADENOPATHIA MAYBEOBSERVEDDURINGTHECOURSEOFDISEASE&ATALINFECTIONSOFFULMINANT HEPATITIS % ARE RARE AND IN THE RANGE OF n ON THE AVERAGE4HEY ARE MOREOFTENOBSERVEDINPREGNANTWOMENWHOAPPEARTOBEEXCEPTIONALLY SUSCEPTIBLETOSEVEREDISEASEFORMSWHERETHEYCANOCCURINUPTOOF (%6INFECTIONWITHALETHALCOURSEOFINFECTION!NYHOW (%6EXHIBITSITS HIGHESTVIRULENCEWITHINTHETHIRDTRIMESTEROFPREGNANCYTHEREASONSFOR THISARENOTSUFFICIENTLYUNDERSTOODUNTILNOW4HEREISALSOAHIGHFREQUENCY OF CASES OF INTRA UTERINE DEATHS AND ABORTIONS IN CASE OF MATERNAL (%6 INFECTION 3URVIVING NEONATES OF INFECTED MOTHERS OFTEN SHOW A CLINICALLY APPARENTACUTE(%6INFECTION !N ALTERED STATUS OF HORMONES AND IMMUNITY ARE OBSERVED DURING PREGNANCY BUT THE ACTUAL CAUSE OF THIS HIGH MORTALITY DURING PREGNANCY ISSTILLUNKNOWN)TISSUGGESTEDTHATDIMINISHEDCELLULARIMMUNITYnINDI CATEDBYADECREASEIN#$ ANINCREASEIN#$CELLCOUNTSANDACONSECU TIVELYLOWERED#$#$CELLRATIOnANDAHIGHLEVELOFSTEROIDHORMONES THATINFLUENCEVIRALREPLICATIONEXPRESSIONDURINGPREGNANCYAPPEARTOBE THE MOST PLAUSIBLE REASON FOR SEVERITY OF THIS DISEASE DURING PREGNANCY ; = 4HEREISMUCHEVIDENCETHAT(%6INFECTIONSINDUCEAGOODANDMOSTLY LIFE LONGIMMUNITYTORE INFECTIONBY(%6



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$IAGNOSTICS 4HEVIRUSCANBEVISUALISEDBYELECTRONMICROSCOPY EG INFAECALSAMPLES 4ODAY MOST OF THE DIAGNOSTICS IS BASED ON IMMUNOLOGICAL METHODS ON THE ANTIBODY LEVEL 3PECIFIC )G- ANTIBODIES TO (%6 OCCUR EARLY n MOSTLY AT THE TIME POINT OF ONSET OF SYMPTOMSJAUNDICE n AND REGULARLY IN (%6 INFECTIONANDCANPERSISTOVERACONSIDERABLYLONGPERIODOFTIMEOFUPTO MONTHSAFTERTHEPEAKOFTHEINFECTION;=!LSOSPECIFIC)G'ANTI (%6ANTI BODIESOCCUREARLYANDREGULARLYPEAKAPPROXIMATELYnWEEKSAFTERCLINI CALMANIFESTATIONSAREOBSERVEDANDREMAINFORATLEASTYEARSDETECTABLE 0ATIENTSWITHADELAYED)G'RESPONSEWEREREPORTED;=&AECAL(%62.! REGULARLYBECOMESPOSITIVEBEFORETHEONSETOFCLINICALSYMPTOMSANDBEFORE SERUM (%6 2.! BECOMES DETECTABLE START OF POSITIVITY GOES ALMOST IN PARALLELWITH)G-)G'SEROCONVERSION $UETOTHESEFACTSMOLECULAR0#2 TECHNIQUESPLAYANIMPORTANTCOMPLIMENTARYROLEINUPTODATE(%6INFEC TIOLOGICALDIAGNOSTICS /F COURSE SPECIFIC LIVER PARAMETER SUCH AS EG SERUM ALANINE AMINO TRANSFERASE!,!4 BILIRUBINETC AREALTEREDSUCHASINOTHERFORMSOFVIRAL HEPATITIS

$ISEASEMANAGEMENTANDPREVENTION )MPROVING THE SOCIOECONOMIC SITUATION n INCLUDING HYGIENIC CONDITIONS nWITHANOPTIMALWASTEWATERMANAGEMENTPROGRAMMEARETHEMOSTEFFEC TIVEMEASURESOFDISEASEMANAGEMENTOFPREVENTING(%6INFECTIONS-OST INFECTIONS APPEAR BEING DUE TO THE CONSUMPTION OF CONTAMINATED @FRESH WATER 4HERE IS MUCH EVIDENCE THAT EVEN INTRA FAMILIAL PERSON TO PERSON TRANSMISSIONONLYPLAYSAVERYMINORROLEUNDERACCEPTABLEHYGIENICCONDI TIONSWHICHREFLECTSTHATTHEDISEASEONITSOWNISNOTEXTREMELYCONTAGIOUS 4HEVIRUSPARTICLEAPPEARSBEINGRELATIVELYLABILEANDCANBEINACTIVATED BY HEATING UP TO nª# OVER A PERIOD OF  MIN OR EVEN BY CYCLES OF FREEZE THAWING 4O DATE THERE IS NO SPECIFIC THERAPY AGAINST (%6 INFECTION AVAILABLE &URTHER APPROACHESOFPASSIVEIMMUNOTHERAPYWITHHYPERIMMUNGLOBULINE SERAnEVENWITHHIGHSPECIFICANTI (%6)G'TITRES DERIVINGFROMENDEMIC AREASnDIDNOTLEADTOCLINICALIMPROVEMENTOFTHECLINICALSITUATION !VACCINEAGAINST(%6INFECTIONINHUMANSISNOTYETAVAILABLEONTHE MARKETHOWEVER DEVELOPMENTOFACANDIDATEVACCINEISINPROGRESSWITHA HIGHVISIBILITYOFSUCCESS;=2ESEARCHONTHISISSUESTARTEDWITHTHEEARLY SUCCESSFULAPPROACHESINCYNOMOLGUSMONKEYSPERFORMEDBY4SAREVETAL IN;=4HEYDISCOVEREDTHATIMMUNISATIONOF#YNOMOLGUSMACAQUES WITHAK$ARECOMBINANT(%6FUSIONPROTEINDERIVINGFROMTHESECOND /2& OF (%6 PROTECTED THE ANIMALS AGAINST EXPERIMENTAL INFECTION WITH (%64HESERESULTSAREPROMISINGFORTHEDEVELOPMENTOFAVACCINE

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OF HEPATITIS % AMONG DISPLACED PERSONS IN $ARFUR 3UDAN #LIN )NFECT $IS  n "RYAN *0 4SAREV 3! )QBAL - 4ICEHURST * %MERSON 3 !HMED! $UNCAN * 2AFIQUI!2 -ALIK )! 0URCELL 2(  %PIDEMIC HEPATITIS % IN 0AKISTAN PATTERNSOFSEROLOGICRESPONSEANDEVIDENCETHATANTIBODYTOHEPATITIS%VIRUS PROTECTSAGAINSTDISEASE*)NFECT$ISn +HUROO-3 2USTGI6+ $AWSON'* -USHAWAR)+ 9ATTOO'. +AMILI3 +HAN "!  3PECTRUM OF HEPATITIS % VIRUS INFECTION IN )NDIA * -ED 6IROL  n ,IN #8 7U 4 7U 8, 8IE -( #HENG 4 ,I 37 :HANG * 8IA .3  0RIMINGWITHAN(%64HEPITOPECANIMPROVETHEHUMORALIMMUNOGENICITYOF ITSNATIVEPROTEIN#HINESE 3HENG7U'ONG#HENG8UE"AOn 4SAREV 3! 4SAREVA43 %MERSON 35 'OVINDARAJAN 3 3HAPIRO - 'ERIN *, 0URCELL2( 3UCCESSFULPASSIVEANDACTIVEIMMUNIZATIONOF#YNOMOLGUS MONKEYSAGAINSTHEPATITIS%0ROC.ATL!CAD3CI53!n

#OMPARATIVE(EPATITIS EDBY/LAF7EBERAND5LRIKE0ROTZER ¥"IRKHËUSER6ERLAG"ASEL3WITZERLAND



"ACTERIALINFECTIONSOFTHELIVER (ILMAR7ISPLINGHOFFAND$ARRYN,!PPLETON )NSTITUTEFOR-EDICAL-ICROBIOLOGY )MMUNOLOGYAND(YGIENE 5NIVERSITYOF#OLOGNE #OLOGNE

'ERMANY $EPARTMENTFOR)NTERNAL-EDICINE 6IRGINIA#OMMONWEALTH5NIVERSITY 2ICHMOND 6! 53!

!BSTRACT "ACTERIAL INFECTIONS OF THE LIVER CAN BE CATEGORISED INTO THREE ENTITIES ACUTE BACTERIAL HEPATITIS BACTERIALLIVERABSCESSESANDGRANULOMATOUSLIVERDISEASECAUSEDBYBACTERIA! BROADSPECTRUMOFBACTERIAHASBEENIMPLICATEDINDIFFERENTFORMSOFHEPATICINFECTIONS ANDAWIDEVARIETYOFSYSTEMICBACTERIALINFECTIONSAFFECTTHELIVERDURINGTHECOURSEOF INFECTION #LINICAL SYMPTOMS CAUSATIVE PATHOGENS AND THERAPEUTIC APPROACHES OVERLAP WIDELY-OSTBACTERIALINFECTIONSTHATAFFECTTHELIVERCAUSESECONDARYHEPATITISWITHONLY DISCRETECLINICALANDLABORATORYFINDINGS3TANDARDDIAGNOSTICPROCEDURESINCLUDINGPHYSI CALEXAMINATION IMAGINGANDMICROBIOLOGICALCULTURESWILLUSUALLYBESUFFICIENTTODETECT ANDASCERTAINTHEBACTERIALCAUSESOFHEPATITIS4HERAPYOFBACTERIALINFECTIONSOFTHELIVER USUALLY INCLUDES ANTIMICROBIAL CHEMOTHERAPY ACCORDING TO STANDARD GUIDELINES FOR THE UNDERLYING DISEASE AND THE IDENTIFIED PATHOGEN AS WELL AS ADDITIONAL INVASIVE THERAPY WHICHMAYBEREQUIREDFORCERTAINMANIFESTATIONS

)NTRODUCTION 4HE LIVER CAN BE AFFECTED BY A WIDE VARIETY OF SYSTEMIC INFECTIONS )N BAC TERIAL INFECTIONS MOST COMMON FORMS OF LIVER INVOLVEMENT ARE PYOGENIC ABSCESSES ACUTEHEPATITISANDGRANULOMATOUSLIVERDISEASE "ACTERIA CAN REACH THE LIVER IN SEVERAL WAYS (EMATOGENOUS SPREAD OF BACTERIAINTOTHELIVERDURINGBLOODSTREAMINFECTIONVIA THEPORTALVEINOR THEHEPATICARTERY DIRECTSPREADOFBACTERIAFROMACONTIGUOUSFOCALINFEC TION VIA THE BILIARY TREE OR FOLLOWING INTERNAL OR EXTERNAL TRAUMA 4HESE INFECTIONSUSUALLYMANIFESTASSO CALLEDPYOGENICABSCESSESTHATARECLINICALLY INDISTINGUISHABLE FROM OTHER ABSCESSES SUCH AS THE AMOEBIC LIVER ABSCESS CAUSEDBY%NTAMOEBAHISTOLYTICA  7HILEVIRUSESARETHEMOSTCOMMONCAUSESOFACUTEHEPATITIS INFECTIONS DUE TO BACTERIA SUCH AS .EISSERIA MENINGITIDIS 3ALMONELLA TYPHI "RUCELLA SPP OR #AMPYLOBACTER SPP HAVE ALSO BEEN ASSOCIATED WITH THIS CLINICAL



(ILMAR7ISPLINGHOFFAND$ARRYN,!PPLETON

ENTITY)NFECTIONSDUETOBACTERIASUCHAS-YCOBACTERIUMSPP 4ROPHERYMA WHIPPLEI 4REPONEMAPALLIDUM #OXIELLABURNETIIOR2ICKETTSIASPPAREAMONG THEMAJORCAUSESOFGRANULOMATOUSLIVERDISEASE 4HIS CHAPTER REVIEWS THE DIFFERENT FORMS OF LIVER DISEASES THAT CAN BE CAUSED BY BACTERIA AND SUMMARISES THE CLINICAL FEATURES AND THERAPEUTIC OPTIONSFORTHEMOSTCOMMONFORMSANDPATHOGENS

2OUTESOFINFECTION 4HEREAREINGENERALFOURMECHANISMSBYWHICHBACTERIALINFECTIONSOFTHE LIVER DEVELOP HAEMATOGENOUS BILIARY CONTIGUOUS SPREAD AND VIA DIRECT INOCULATION (AEMATOGENOUSSEEDINGOFBACTERIACANOCCURVIATHEPORTALVEINORTHE HEPATICARTERYFROMTHESYSTEMICCIRCULATIONANDAREFREQUENTLYASSOCIATED WITHPERITONITIS DIVERTICULITISORGENERALISEDBLOODSTREAMINFECTIONORSEPSIS )NTHEPRE ANTIBIOTICERA THEHAEMATOGENOUSROUTEWASTHEMOSTCOMMON METHOD OF INFECTION AND INFECTION USUALLY ORIGINATED FROM APPENDICEAL PATHOLOGY ;=4ODAY BACTERIAL INFECTIONS OF THE LIVER ARE MOST COMMONLY ASSOCIATEDWITHBILIARYDISEASE; = 5NDERLYINGCONDITIONSLEADINGTOBACTERIALINFECTIONSOFTHELIVERVIATHE BILIARY TREE ARE MOST COMMONLY CHOLANGITIS CHOLECYSTITIS OR MALIGNANCIES SUCHASCHOLANGIOCARCINOMA;= 4RANSLOCATION OF BACTERIA FROM INFECTIOUS PROCESSES IN CLOSE PROXIMITY OFTHELIVERSUCHASAPPENDICITIS DIVERTICULITISANDOTHERINFLAMMATORYPRO CESSES OF THE INTESTINE ARE LESS FREQUENT ALTHOUGH CONTIGUOUS SPREAD FROM THELUNG KIDNEY COLONORTHESTOMACHHASBEENREPORTED; n= 4HERE ARE TWO POTENTIAL MECHANISMS OF DIRECT INFECTION IATROGENIC FOL LOWING INVASIVE PROCEDURES SUCH AS %2#0 PERCUTANEOUS LIVER BIOPSY ;= ORABDOMINALSURGERY;=ACCOUNTINGFORAPPROXIMATELYOFALLPYOGENIC ABSCESSESOFTHELIVER ORVIAPENETRATINGTRAUMATHROUGHTHESKINORSECOND ARYTOACCIDENTALINGESTIONOFSHARPOBJECTSSUCHASFISHBONES;=ORTOOTH PICKS;=ACCOUNTINGFORAPPROXIMATELY;= #RYPTOGENICINFECTIONSWHERETHEROUTEOFINFECTIONANDORTHEUNDERLY INGCONDITIONCANNOTBEIDENTIFIEDACCOUNTFORnOFABSCESSESBASED ONDATAFROMSEVERALSTUDIES;   =

#LINICALENTITIES "ACTERIAL INFECTIONS OF THE LIVER CAN BE CATEGORISED INTO THREE ENTITIES ACUTE BACTERIAL HEPATITIS BACTERIAL PYOGENIC LIVER ABSCESSES AND GRANU LOMATOUS LIVER DISEASE CAUSED BY BACTERIA 7HILE THIS DIFFERENTIATION REMAINSLARGELYTHEORETICALINMOSTINFECTIONSBECAUSECLINICALSYMPTOMS CAUSATIVE PATHOGENS AND THERAPEUTIC APPROACHES OVERLAP WIDELY DIFFER

"ACTERIALINFECTIONSOFTHELIVER



ENCESINOUTCOMEHAVEBEENREPORTEDINPATIENTSWITHLIVERINFECTIONDUE TO,ISTERIAMONOCYTOGENES;=

"ACTERIALHEPATITIS !MONG THEVARIOUSCAUSES OFACUTE HEPATITIS BACTERIAL INFECTIONS ARE RELA TIVELY RARE "LOODSTREAM INFECTIONS AND SEVERE SEPSIS OR SEPTIC SHOCK CAN CAUSE HEPATIC ISCHAEMIA THAT CAN PRESENT AS AN ACUTE HEPATITIS! VARIETY OFORGANISMSHASBEENDESCRIBEDASCAUSATIVEAGENTSOFHEPATITIS INCLUDING "ARTONELLAHENSELAE "ORRELIABURGDORFERI "RUCELLAABORTUS #HLAMYDIASPP #OXIELLABURNETII &RANCISELLATULARENSIS ,EGIONELLAPNEUMOPHILA ,EPTOSPIRA INTERROGANS SL ,ISTERIA MONOCYTOGENES -YCOBACTERIUM SPP 3ALMONELLA SPP 4REPONEMAPALLIDUM AND9ERSINIAPESTIS;=

"ACTERIALABSCESSES 0YOGENICABSCESSESARETHEMOSTCOMMONFORMOFBACTERIALINFECTIONSOF THELIVERANDDEVELOPINnPATIENTSPER HOSPITALADMISSIONS;  n="ACTERIALABSCESSESACCOUNTFORABOUTOFALLLIVERABSCESSES ININDUSTRIALISEDCOUNTRIES WHILEINCOUNTRIESOFTHE4HIRD7ORLDPARASITIC ABSCESSESAREMOREFREQUENT;=,IVERABSCESSESFREQUENTLYDEVELOPVIA DIRECT SPREAD FOLLOWING OBSTRUCTION OF THE BILIARY TREE OR INFECTIONS OF THEGASTROINTESTINALTRACTSUCHASDIVERTICULITISORPEPTICULCERDISEASEBUT CAN ALSO BE ASSOCIATED WITH ABDOMINAL SURGERY OR MALIGNANCIES IN THE CLOSEPROXIMITYOFTHELIVER#ONSEQUENTLY INCIDENCEISHIGHESTINPATIENTS BETWEENANDYEARS;  =-OSTSTUDIESDIDNOTIDENTIFYANYSIG NIFICANTDIFFERENCESINGENDERANDDIDNOTDETECTANYCLEARGEOGRAPHICPAT TERNS; =4HEINCIDENCEOFBACTERIALLIVERABSCESSESHASBEENINCREASING OVER THE PAST DECADE -ORTALITY HAS DECREASED CONSIDERABLY DURING THAT TIME MOSTLYDUETOADVANCESINIMAGINGANDANTIMICROBIALCHEMOTHERAPY ;= 4HE MOST IMPORTANT DIFFERENTIAL DIAGNOSIS IS LIVER ABSCESS DUE TO OTHER CAUSES MOSTCOMMONLYAMOEBICLIVERABSCESSESCAUSEDBYINFECTIONWITH% HISTOLYTICA EVENTHOUGHAPPROXIMATELYOFAMOEBICABSCESSESALSOYIELD BACTERIA; =

'RANULOMATOUSHEPATITISDUETOBACTERIALINFECTIONS )NVOLVEMENTOFTHELIVER MOSTLYINTHEFORMOFGRANULOMATOUSLIVERDISEASE CAN BE AN IMPORTANT MANIFESTATION OF CERTAIN BACTERIAL INFECTIONS4HE DIF FERENTIALDIAGNOSISINCLUDESDISEASESCAUSEDBYANUMBEROFVIRALEG (!6 (#6 #-6 %"6 OR PARASITIC EG ,EISHMANIA 3CHISTOSOMA 4OXOCARA



(ILMAR7ISPLINGHOFFAND$ARRYN,!PPLETON

#LONORCHIS AGENTSWHICHAREDISCUSSEDELSEWHEREINTHISBOOK ASWELLASA VARIETYOFNONINFECTIOUSCAUSESSUCHASDRUGINDUCEDLIVERDISEASE PRIMARY BILIARYCIRRHOSIS NEOPLASTICANDMALIGNANTDISORDERS ASWELLASSYSTEMICDIS EASESSUCHASSARCOIDOSIS

#LINICALFEATURES -OSTBACTERIALINFECTIONSAFFECTINGTHELIVERCAUSESECONDARYHEPATITISWITH MILD TO MODERATE ELEVATION OF LIVER ENZYMES MAINLY!,4 !34 ALKALINE PHOSPHATASE ANDONLYDISCRETECLINICALSYMPTOMS-ANYSYSTEMICBACTERIAL INFECTIONSONLYINVOLVETHELIVERTOARELATIVELYMINOREXTENTANDARETHERE FORENOTPRIMARILYCLASSIFIEDASHEPATITISHOWEVER SOMEINFECTIONSSUCHAS LEPTOSPIROSIS7EILSDISEASE ORSYPHILISMAYPRESENTWITHTHECLASSICALSIGNS ANDSYMPTOMSOFANACUTEHEPATITIS #LINICALSYMPTOMSSUCHASABDOMINALPAIN TYPICALLYINTHERIGHTUPPER QUADRANT ANDFEVERMAYPRESENTWITHANACUTEONSETANDSEVERECOMPLICA TIONSSUCHASPNEUMOPERITONEUMFOLLOWINGTHERUPTUREOFAGASCONTAINING ABSCESSHAVEBEENDESCRIBED;=-OREOFTEN HOWEVER SYMPTOMSARENON SPECIFICANDCANINCLUDEGENERALWEAKNESS HEADACHE MYALGIA ANDNAUSEA ; = 0ATIENTS TYPICALLY PRESENT WITH SLOWLY PROGRESSIVE VAGUE CONSTITU TIONALSYMPTOMSSUCHASFATIGUE ANOREXIAANDFEVER;n=4IMEBETWEEN THE ONSET OF SYMPTOMS AND DIAGNOSIS AVERAGES  WEEKS BUT INTERVALS OF GREATERTHANWEEKSHAVEBEENREPORTED;=$EPENDINGONTHESIZEAND THELOCATIONOFTHEABSCESS MORESPECIFICSYMPTOMSSUCHASNAUSEA DIFFUSE ABDOMINALDISCOMFORT PLEURITICCHESTPAIN REFERREDRIGHTSHOULDERDISCOM FORTCAUSEDBYLESIONSNEARTHEDIAPHRAGM ORBILIARYOBSTRUCTIONANDMILD JAUNDICECAUSEDBYABSCESSESCOMPRESSINGTHEBILIARYTREEMAYBEPRESENT ; n=/NLYBETWEENANDOFPATIENTSPRESENTWITHTHECLAS SICALTRIADOFJAUNDICE FEVERANDTENDERNESSINTHERIGHTUPPERQUADRANT;  =)NARECENTSERIESFEVERWASTHEMOSTCOMMONSYMPTOM PRESENTING INAPPROXIMATELYOFCASES FOLLOWEDBYABDOMINALPAIN NAUSEA  WEIGHTLOSS PLEURALEFFUSIONS ANDHEPATOMEGALYAND JAUNDICEn ; = 0HYSICALEXAMINATIONGENERALLYREFLECTSTHECLINICALSYMPTOMS HIGHLIGHT INGTHENON SPECIFICNATUREOFTHEPRESENTATIONINMANYPATIENTS;  = ,EUKOCYTOSISPRESENTINnOFPATIENTS; = TWO TOTHREE FOLD INCREASEDALKALINEPHOSPHATASEANDELEVATIONINTHESERUM# REACTIVEPRO TEIN#20 OFTENINCOMBINATIONWITHANAEMIA DECREASEDSERUMALBUMIN ANDELEVATEDBILIRUBINARETHEMOSTCOMMONLYSEENLABORATORYABNORMALI TIES;  = )N CONTRAST LIVER FUNCTION TESTS CAN BE NORMAL OR SHOW ONLY SLIGHT TO MODERATE DEVIATIONS FROM THE NORMAL VALUES!LKALINE PHOSPHATASE !0 ISMOSTCOMMONLYELEVATED ALANINEAMINOTRANSFERASE!,4 ANDASPARTATE AMINOTRANSFERASE !34 ARE ELEVATED MOSTLY IN PATIENTS WITH PRIMARY OR

"ACTERIALINFECTIONSOFTHELIVER



SECONDARY BILIARY INVOLVEMENT WHILE ALBUMIN AND PROTHROMBIN TIME ARE OFTENWITHINNORMALLIMITS $UE TO THE NON SPECIFIC NATURE OF CLINICAL AND SOMETIMES ALSO LABORA TORY FINDINGS DIAGNOSISOFBACTERIALHEPATITISUSUALLYREQUIRESAHIGHDEGREE OFSUSPICION-OSTOFTHEIMPORTANTDIFFERENTIALDIAGNOSESSUCHASAMOEBIC LIVERABSCESS CHOLECYSTITISANDPYELONEPHRITISCANNOTBERULEDOUTONCLINI CALSIGNSALONE3INCETHEREAREAVARIETYOFUNDERLYINGCONDITIONSTHATCAN LEAD TO ABSCESSES IN THE LIVER DIAGNOSIS MAY BE MISSED INITIALLY ESPECIALLY INABSCESSESOCCURRINGINTHEWAKEOFABDOMINALSURGERYOROTHERINVASIVE PROCEDURESWHERESYMPTOMSSUCHASPAINANDFEVERMAYWELLBERELATEDTO THEUNDERLYINGCONDITION -ORTALITY RATES HAVE DECREASED SUBSTANTIALLY OVER THE PAST SEVERAL DECADES WITHRECENTSTUDIESREPORTINGRATESOFn;=

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4HERAPY 4HERAPYOFBACTERIALINFECTIONSOFTHELIVERUSUALLYCONSISTSOFANTIMICROBIAL CHEMOTHERAPY ACCORDING TO STANDARD GUIDELINES FOR THE UNDERLYING DIS EASE AND THE IDENTIFIED PATHOGEN $UE TO INCREASING RESISTANCE ESPECIALLY IN ENTEROBACTERIACEAE CULTURE OF THE CAUSATIVE PATHOGENS SHOULD ALWAYS BE ATTEMPTED AND SUSCEPTIBILITIES OF IDENTIFIED BACTERIA SHOULD ALWAYS BE ASCERTAINED)NSOMECASES SUCHASFULMINATELEPTOSPIROSIS FULLSUPPORTIVE THERAPYINTHEINTENSIVECAREUNITMAYBENECESSARY !LTHOUGHTHEREARESOMEREPORTSOFCUREBYANTIBIOTICTREATMENTWITH OUTSURGERY; = DRAINAGEOFABSCESSESISUSUALLYESSENTIAL;= 0ERCUTANEOUS TRANSHEPATIC DRAINAGE IS A RELATIVELY LOW RISK PROCEDURE THAT HAS REPLACED OPEN SURGERY AS THE METHOD OF CHOICE ;    = 0ERCUTANEOUS CATHETER DRAINAGE 0#$ AND PERCUTANEOUS NEEDLE ASPIRA TION0.! SHOULDBEATTEMPTEDIFTHEREISONELARGEANDACCESSIBLEABSCESS 4HESE METHODS HAD A HIGH SUCCESS RATE n WHILE MORTALITY WAS RELATIVELYLOW; =)NCOMPARISONOFBOTHTECHNIQUES 9UANDCO WORKERS CONCLUDED THAT INTERMITTENT NEEDLE ASPIRATION IS PROBABLY AS EFFECTIVE AS CONTINUOUS CATHETER DRAINAGE FOR THE TREATMENT OF PYOGENIC LIVER ABSCESS ANDRECOMMENDEDITSHOULDBECONSIDEREDASAFIRSTLINEAPPROACHDUETO THE ADDITIONAL ADVANTAGES OF PROCEDURE SIMPLICITY PATIENT COMFORT AND REDUCEDPRICE;= $UETOTHEEQUIVALENTEFFICACYOF0#$0.!TOSURGICALTHERAPYANDTHE HIGHER MORTALITY OF THE LATTER UP TO  MOST AUTHORS RECOMMEND AN OPENSURGICALAPPROACHONLYINSELECTEDCASES; =2ECENTSTUDIESALSO DESCRIBE ENDOSCOPIC DRAINAGE OF PYOGENIC LIVER ABSCESSES WITH SUSPECTED BILIARY ORIGIN AND CONCLUDE THAT %2#0 ENABLES NOT ONLY DEMONSTRATION OF COMMUNICATIONS BETWEEN THE BILIARY TRACT AND LIVER ABSCESSES BUT ALSO THATANINTERNALDRAINAGEOFTHECAVITYISFEASIBLEANDSAFE;=)NCONTRAST OTHERSFOUNDTHATFORLARGELIVERABSCESSESOFMORETHANCM OPENSURGICAL DRAINAGEPROVIDESBETTERCLINICALOUTCOMESTHAN0#$INTERMSOFTREATMENT SUCCESS NUMBER OF SECONDARY PROCEDURES AND HOSPITAL STAY WITH COMPA RABLEMORBIDITYANDMORTALITYRATES;= 3INCE ABSCESSES ARE OFTEN POLYMICROBIAL INITIAL THERAPY UTILISING BROAD SPECTRUM ANTIBIOTICS WITH ANAEROBIC COVERAGE IS RECOMMENDED !NTIMICROBIAL AGENTS RECOMMENDED AS FIRST LINE DRUGS INCLUDE BETA LACTAMBETA LACTAMASE INHIBITOR COMBINATIONS FOR EXAMPLE AMPICIL LINSULBACTAM OR PIPERACILLINTAZOBACTAM IN COMBINATION WITH A THIRD GENERATIONCEPHALOSPORIN ORAFLUROQUINOLONEORINCASESOFNOSOCOMIAL INFECTIONS ANDOR PRETREATED PATIENTS CARBAPENEMS FOR EXAMPLE IMIPE NEM MEROPENEM ; = /THER FACTORS SUCH AS UNDERLYING CONDITIONS ORPROBABLESOURCEOFINFECTIONCANALSOINFLUENCETHEDECISIONONINITIAL ANTIMICROBIALTHERAPY 4HERAPYSHOULDBEADJUSTEDASSOONASRESULTSFROMBLOODCULTURESAND FROMCULTURESOFTHEABSCESSAREAVAILABLE

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#ONCOMITANT BACTERAEMIA IS REPORTED IN ABOUT HALF THE CASES OF BACTE RIALABSCESSES;= BUTSOMEAUTHORSREPORTEDBLOODSTREAMINFECTION"3) IN UP TO  OF PATIENTS WITH LIVER ABSCESSES DUE TO + PNEUMONIAE ;= %XTRAHEPATICABSCESSESHAVEBEENDESCRIBEDINONLYnOFTHESEPATIENTS ;  =3ECONDARYABSCESSESAREMOSTOFTENENCOUNTEREDINTHEEYE; =BUTAVARIETYOFOTHERSITESHASBEENDESCRIBEDSUCHASTHELUNGPLEURA ; = KIDNEY;=PROSTATE; = #.3MENINGES;   = BONES ;=ANDSKINANDSOFT TISSUE;  =$IABETESMELLITUSANDALCOHOLISM HAVE BEEN IDENTIFIED AS SIGNIFICANT RISK FACTORS FOR DEVELOPING METASTATIC INFECTIONS FROM PYOGENIC LIVER ABSCESSES ;= )N LIVER INFECTIONS DUE TO + PNEUMONIA RECENT STUDIES FOUND THE + GENOTYPE TO BE ASSOCIATED WITH METASTATICCOMPLICATIONS;= )NCONTRASTTOOTHER%NTEROBACTERIACEAE 3ALMONELLASPP MAINLY3TYPHI RARELYCAUSEHEPATICABSCESSES EVENTHOUGHTHEREHAVEBEENSOMEREPORTS INCLUDING ONE RECENT CASE OF SALMONELLOSIS WITH SEPTIC SHOCK AND LIVER ABSCESS IN A DIABETIC AND CIRRHOTIC PATIENT ;= %VEN IN IMMUNOCOMPRO MISEDPATIENTSSUCHASPATIENTSWITH()6!)$3WHEREBACTERAEMIADUETO NON TYPHI 3ALMONELLA IS MORE FREQUENT THAN IN IMMUNOCOMPETENT HOSTS FOCALCOMPLICATIONSINVOLVINGTHELIVERHAVEBEENRARELYDESCRIBED;= 'ENERALLY INPATIENTSWITHTYPHOIDFEVER THEUSUALHISTOLOGICFINDINGOF THELIVERISNONSPECIFICREACTIVEHEPATITISANDOTHERMANIFESTATIONSSUCHAS HEPATIC GRANULOMA ARE RARE COMPLICATIONS OF TYPHOID FEVER ;= 3YSTEMIC INFECTIONS DUE TO 3ALMONELLA SPP OFTEN INVOLVE THE LIVER MAINLY DURING THE BACTEREMIC PHASE OF INFECTION )N ALMOST HALF OF THE INFECTIONS DUE TO 3TYPHIHEPATOSPLENOMEGALYANDSEVEREIMPAIRMENTOFLIVERFUNCTIONSCAN BEOBSERVED4HEREHAVEBEENMORETHANCASESOFSALMONELLAHEPATITIS REPORTEDANDINCIDENCESRANGEFROMLESSTHANTOOFPATIENTSWITH ENTERICFEVER7HILEEXTREMEHEPATICDYSFUNCTIONISARARECOMPLICATIONIN 3ALMONELLAHEPATITIS TYPHOIDNODULESWITHMARKEDHYPERPLASIAOFRETICULO ENDOTHELIALCELLSISUSUALLYOBSERVED3PECIFICANTIMICROBIALTHERAPYISUSU ALLYEFFECTIVEBUTSEVERECLINICALCOURSESWITHMORTALITYRATESUPTOHAVE BEENREPORTED;  = .EISSERIAMENINGITIDIS.EISSERIAGONORRHOEAE 4HE LIVER CAN BE AFFECTED DURING THE BACTERAEMIA THAT MAY OCCUR DURING MENINGOCOCCALORGONOCOCCALINFECTIONS !CUTE PERIHEPATITIS DUE TO . GONORRHOEAE ONE ETIOLOGY OF THE &ITZ (UGH #URTIS SYNDROME IS MAINLY ENCOUNTERED IN FEMALE PATIENTS WITH PELVICINFLAMMATORYDISEASEANDCANDEVELOPEVENMONTHSAFTERTHEPRIMARY INFECTION ;= 4HE INCIDENCE OF THIS COMPLICATION OF PELVIC INFLAMMATORY DISEASEWASRELATIVELYLOW INRECENTSERIES;= 2ECENTLYCHOLESTATICHEPATITISHASBEENREPORTEDINACHILDIN4URKEYFOL LOWINGCHRONICMENINGOCOCCAEMIA;=(EPATITISDEVELOPEDFOURDAYSAFTER THEINITIALPRESENTATIONTHATINCLUDEDFEVER ARTHRALGIAANDAMACULOPAPULAR RASH WHILETHEPATIENTWASTREATEDWITHPENICILLINCONSISTENTWITHTHESUSCEP

"ACTERIALINFECTIONSOFTHELIVER



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INFECTIONSOFTHELIVERTHAN'RAM NEGATIVEPATHOGENS;  =)NADDITION THESE ORGANISMS ARE MORE LIKELY TO BE RECOVERED FROM MONOBACTERIAL SEC ONDARYABSCESSESINPATIENTSWHERETHEPRIMARYFOCUSOFINFECTIONISUSUALLY LOCATEDOUTSIDETHEABDOMEN )NRECENTSTUDIES 3PNEUMONIAEHASBEENREPORTEDASTHECAUSEOFLIVER INFECTIONSMAINLYINIMMUNOCOMPROMISEDHOSTS!LCOHOLISM ()6INFECTION SPLENECTOMY CONNECTIVE TISSUE DISEASE STEROID USE DIABETES MELLITUS AND INTRAVENOUSDRUGUSEREMAINCOMMONRISKFACTORSFORINVASIVEPNEUMOCOC CALINFECTIONS;= ,ISTERIAMONOCYTOGENES ,ISTERIA MONOCYTOGENES CAUSES SEPSIS AND MENINGITIS IN IMMUNOCOMPRO MISED PATIENTS AND A DEVASTATING MATERNALFETAL INFECTION IN PREGNANT WOMEN ;  = 6ARIOUS OUTBREAKS DEMONSTRATED THAT , MONOCYTO GENES CAN CAUSE GASTROENTERITIS IN OTHERWISE HEALTHY INDIVIDUALS AND MORE SEVEREINVASIVEDISEASEINIMMUNOCOMPROMISEDPATIENTS;  = -ATERNALLISTERIOSISUSUALLYRESULTSINANONSPECIFICFEBRILEILLNESSTHATIS RARELYDIAGNOSEDPREPARTUMABOUTONETHIRDOFPATIENTSHAVENOSYMPTOMS ATALL ; =BUTMAYLEADTOSPONTANEOUSABORTION STILLBIRTH DEATHOFTHE NEWBORNWITHINHOURSAFTERBIRTH ORNEONATALSEPSISORRESULTINGRANULOMA TOSISINFANTISEPTICA CHARACTERISEDBYMICROABSCESSESANDGRANULOMASINTHE LIVERANDSPLEEN; = )NADULTSTHEREAREANUMBEROFATYPICALCLINICALFORMSOFLISTERIOSISn OFCASES INCLUDINGENDOCARDITISTHETHIRDMOSTFREQUENTFORM MYO CARDITIS HEPATITIS COLECYSTITIS LOCALISEDABSCESSES;=4ODATETHEREARE CASESOFHEPATICLISTERIOSISDESCRIBEDINTHELITERATURE WITHCLINICALPRESEN TATIONSINCLUDINGSOLITARYLIVERABSCESSES MULTIPLEABSCESSESANDDIFFUSEOR GRANULOMATOUS HEPATITIS WHICH DIFFER IN CLINICAL COURSE AND OUTCOME ;= $ETAILSOFTHECLINICALFEATURES DIAGNOSTICMODALITIESANDTREATMENTOPTIONS HAVERECENTLYBEENREVIEWEDINDETAILBY3CHOLINGANDCOLLEAGUES;=

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"ACTERIALINFECTIONSOFTHELIVER



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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



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)MMUNERESPONSE )NFECTIONSWITH%NTAMOEBAHISTOLYTICAREGULARLYINDUCEASPECIFIC" AND4 CELLRESPONSE%VENINTHECASEOFASYMPTOMATICINFECTIONSSERUMANTIBODIES TO%NTAMOEBAHISTOLYTICACANBEDETECTEDINMORETHANOFCASES

$IFFERENTIALDIAGNOSISANDDIAGNOSIS )N THE CASE OF ENTERITIS OR COLITIS OTHER INTESTINAL INFECTIOUS AGENTS SHOULD ALWAYSBERULEDOUT)NTHECASEOFMARKEDMUCOSALLESIONSULCERATIVECOLITIS SHOULD BE CONSIDERED !N AMOEBIC LIVER ABSCESS SHOULD BE DIFFERENTIATED FROMABACTERIALABSCESS&URTHERDIFFERENTIALDIAGNOSESAREECHINOCOCCOSIS ORANECROTICTUMOUR 4HE DIAGNOSTIC WORKUP OF INVASIVE AMOEBIASIS DEPENDS ON THE SITE OF MANIFESTATION OF THE ILLNESS A )N THE CASE OF INTESTINAL AMOEBIASIS RECTO SCOPICORCOLONOSCOPICDETECTIONOFAPPROPRIATEMUCOSALLESIONSANDDIRECT DETECTIONOFTHEPATHOGENARETHEPRIMARYMEASURES4HELATTERISPERFORMED BYEXAMINATIONOFTHESTOOLS&IGSAND ORBYHISTOLOGICALDETECTIONOF

164

Achim Harder and Heinz Mehlhorn

Figure 4. Computer tomographies of a liver with an abscess due to E. histolytica amoebae in biopsy material; b) In extraintestinal amoebiasis imaging procedures such as ultrasound and computed tomography are used to detect appropriate organ manifestations and structural defects. At the same time serological detection of specific antibodies to Entamoeba histolytica is an important, often pivotal diagnostic tool. To distinguish it from other apathogenic intestinal amoebae (e.g., Entamoeba dispar), particularly in the case of asymptomatic infections, Entamoeba histolytica should also be characterised immunologically or genetically. Immunological characterisation using monoclonal antibodies to specific epitopes of Entamoeba histolytica is also available as well as the genetic characterisation on the basis of specific DNA sequences, e.g., within the rRNA gene. The genome of Entamoeba histolytica is currently being sequenced. It probably comprises 20 megabases which are distributed over 14 chromosomes.

Treatment Infection with Entamoeba histolytica must always be treated. Asymptomatic intestinal Entamoeba histolytica infections should be treated with diloxanide fuorate or paromomycin for 10 days. All Entamoeba histolytica infections with intestinal or extraintestinal clinical manifestations

#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



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!CHIM(ARDERAND(EINZ-EHLHORN

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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



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!CHIM(ARDERAND(EINZ-EHLHORN

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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



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4REATMENT )NTHEPASTFEWYEARS THEREHASBEENACONSIDERABLECHANGEINTHESTRATEGIES



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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



!LVEOLARECHINOCOCCOSIS%CHINOCOOCUSMULTILOCULARIS;  n n= 3YNONYM 3MALLFOXTAPEWORM

4AXONOMY 3UBREGNUM 0HYLUM #LASS /RDER &AMILY 'ENUS

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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



RESULTOFCOMPRESSIONOFMAJORVESSELSINTHELIVER4HEPATHOGENSGROWTHBY INFILTRATIONCAUSESDIFFERENTSIGNSANDSYMPTOMSACCORDINGTOWHICHORGANS AREAFFECTED !BDOMINAL ORGANS ARE RECEPTIVE TO GROWTH OF THE ALVEOLAR MASS DROP METASTASES  ,YMPH NODES ARE ALSO COLONISED (AEMATOGENOUS DISSEMI NATION OF DETACHED GERMINAL LAYER CELLS EG UNDIFFERENTIATED CELLS ACT LIKE TUMOUR CELLS MAY LEAD TO SEEDING IN OTHER ORGANS 3UCH METASTASIS IS FAVOURED BY IMMUNOSUPPRESSION4HE SPREAD OF THE PARASITIC MASS AT THE TIME OF DIAGNOSIS IS CURRENTLY DESCRIBED USING AN ANATOMICAL DISTRIBUTION PATTERN SIMILAR TO THE4.- SYSTEM 0.- CLASSIFICATION OF THE %UROPEAN %CHINOCOCCOSIS7ORKING'ROUP 

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!CHIM(ARDERAND(EINZ-EHLHORN

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#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



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!NIMALIA 0LATYHELMINTHES 4REMATODA $IGENEA 3CHISTOSOMATIDA 3CHISTOSOMATIDAE 3CHISTOSOMA 3MANSONI 3JAPONICUM 3MEKONGI 3INTERCALATUM 3HAEMATOBIUM

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&IGURE,IGHTMICROGRAPHOFANADULT&ASCIOLAHEPATICAASASSEENFROMITSVENTRALSIDE &IGURE  3CANNING ELECTRON MICROGRAPH OF THE ANTERIOR REGION OF AN ADULT & HEPATICA FLUKE SHOWINGTHEORALANDTHELARGERVENTRALSUCKER THEIN BETWEENSITUATEDTWOSMALLGENITALOPEN INGSANDTHETYPICALSCALYSURFACEBYTOOTHEDTEGUMANTALSCALES &IGURE#UTOFFBILEDUCTWITHADULT&ASCIOLAFLUKES &IGURE,IGHTMICROGRAPHOFANADULT$DENDRITICUMFLUKE &IGURE3CANNINGELECTRONMICROGRAPHOFTHEANTERIORENDOFANADULT$DENDRITICUMFLUKE .OTETHESMOOTH NOTSCALYSURFACE &IGURE,IGHTMICROGRAPHOFANUNSTAINEDADULT#LONORCHISSINENSIS &IGURE3CANNINGELECTRONMICROGRAPHOFTHEVENTRALSIDEOFANADULT#SINENSISFLUKE.OTE THESMOOTH UNSCALYSURFACE &IGURE,IGHTMICROGRAPHOFANADULT/PISTHORCHISVIVERRINIWORM.OTETHESOLIDPOSTERIOR TESTES

#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx





















!CHIM(ARDERAND(EINZ-EHLHORN

















#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



4RANSMISSION MULTIPLICATIONANDINCUBATIONPERIOD 4RANSMISSIONOFSCHISTOSOMESTOHUMANSISPOSSIBLEINFRESHWATERCONTAIN ING THE CERCARIAE FORK TAILED LARVAE EXCRETED BY THE SNAILS4HE CERCARIAE CAN ACTIVELY PENETRATE THE SKIN WITHIN A SHORT SPACE OF TIME 3INCE THE SNAIL SPECIES THAT SERVE AS INTERMEDIATE HOSTS OCCUR ONLY IN SUB TROPICAL CLIMATICZONES TRANSMISSIONCANONLYTAKEPLACEINWATERSINTHOSEREGIONS #ONSTRUCTIONOFIRRIGATIONSYSTEMSIN!FRICAINPARTICULARHASLEDTOADRA MATICINCREASEINREPRODUCTIONOFTHEINTERMEDIATEHOSTSNAILS RESULTINGIN INCREASEDTRANSMISSION 3CHISTOSOMESARETWO HOSTHELMINTHSWITHDIFFERENTDEFINITIVEANDINTER MEDIATE HOSTS ADULT FLUKES RESIDE IN THE DEFINITIVE  FINAL HOST HUMANS (ERE EGGEXCRETIONWITHSTOOLSORURINEOCCURSnDEPENDINGONTHESPECIES -IRACIDIA HATCH IN FRESHWATER PENETRATE AN INTERMEDIATE HOST PARTICULAR FRESHWATER OR AMPHIBIAN SPECIES OF SNAIL AND LARVAL DEVELOPMENT AND MULTIPLICATION OCCUR INSIDE THE SNAIL SPOROCYSTS CERCARIAE  4HEREAFTER CERCARIAESWARMINTOTHEWATERANDACTIVELYPENETRATEPERCUTANEOUSLYINTO HUMANS MIGRATE WITHIN THE DEFINITIVE HOST MATURE INTO ADULT WORMS AND COLONISETHESPECIES SPECIFICVENOUSPLEXUSES 4HEBLOODFLUKESPRINCIPALMULTIPLICATIONPHASETAKESPLACEATTHELARVAL STAGE IN THE INTERMEDIATE HOST SNAIL4HE NUMBER OF WORMS HARBOURED BY THEDEFINITIVEHOSTMAN ISTHESAMEASTHENUMBEROFPENETRATINGCERCARIAE ONECERCARIADEVELOPSTOONEMALEORFEMALEADULTWORMACCORDINGTOITS SEXCHROMOSOMES -ULTIPLICATIONINTHEDEFINITIVEHOSTCONSISTSSOLELYOFTHE PRODUCTIONOFEGGS4HESEMUSTFINDTHEIRWAYINTOWATERINORDERTODEVELOP FURTHER

&IGURE,IGHTMICROGRAPHOFACOUPLEOF3CHISTOSOMAMANSONI &IGURE3CANNINGELECTRONMICROGRAPHOFACOUPLEOF3MANSONI &IGURE,IGHTMICROGRAPHOFASECTIONTHROUGHALIVERGRANULOMEDUETOACENTRALLYLOCATED EGGOF3MANSONI &IGURE%NDOSCOPYOFTHEINNERSURFACEOFAHUMANBLADDERSHOWINGMANYGRANULOMASDUE TOPROTRUDINGEGGSOF3CHISTOSOMAHAEMATOBIUM &IGURE SEEP &IGURE,IGHTMICROGRAPHOFALARVAOFHOOKWORMS &IGURE'IEMSASTAINEDMICROFILARIAFROMBLOODSMEAR &IGURE!DULTOF!RMILLIFERANNULATUS &IGURE!ANNULATUSSCANNINGELECTRONMICROGRAPHOFTHEANTERIORENDWITHMOUTHHOOKS



!CHIM(ARDERAND(EINZ-EHLHORN

!NINCUBATIONPERIODISDEFINABLEONLYIFAHOSTISSIMULTANEOUSLYINFEST EDWITHNUMEROUSCERCARIAE0ENETRATIONBYTHECERCARIAEMAYLEADSHORTLY AFTERWARDSTOCERCARIALDERMATITIS FOLLOWEDAFEWWEEKSLATERBYTHEFEBRILE SYSTEMICDISORDERKNOWNAS+ATAYAMASYNDROME

%PIDEMIOLOGY 7HILE3INTERCALATUMISALMOSTEXCLUSIVELYAHUMANPARASITE 3MANSONIALSO OCCURSINANUMBEROFRODENTSPECIES TOO!LSOTHEFORMOFSCHISTOSOMIASIS CAUSEDBY3JAPONICUMISAZOONOSISWITHCATTLE BUFFALO PIGS RODENTS ETC ASDEFINITIVEHOSTS)NTHECASEOF3MEKONGI DOGSANDPIGSACTASANANIMAL RESERVOIR !NYONE LIVING IN ENDEMIC AREAS WITH OCCUPATIONAL CONTACT WITH WATER EG RICE GROWING LAUNDRY WORK IS EXPOSED TO THE RISK OF 3CHISTOSOMA INFECTION3IMILARLY ANYONETRAVELLINGTOTHETROPICSISATRISKOFCONTRACTING SCHISTOSOMIASISWHENSWIMMINGORCOMINGINTOCONTACTINSOMEOTHERWAY WITHINFECTEDWATERS 3CHISTOSOMIASISCANONLYOCCURINREGIONSINWHICHTHEVECTORSNAILSLIVE AND3CHISTOSOMAEGGSPASSINTOWATERSWITHFAECESANDORURINE4HISISTHE CASEINOVERCOUNTRIESINHOTREGIONS)TISESTIMATEDTHATWAYOVER MILLIONPEOPLEAREINFECTEDWORLDWIDEIN!FRICAANDTHE-IDDLE%ASTWITH3 HAEMATOBIUMTHISSPECIESDOESNOTAFFECTTHELIVERBUTTHEURINARYTRACT OR 3MANSONI IN,ATIN!MERICAWITH3MANSONI IN#HINAANDTHE0HILIPPINES WITH3JAPONICUM IN,AOSAND#AMBODIAWITH3MEKONGIANDINTROPICAL !FRICAWITH3INTERCALATUM

$ISEASESANDSYMPTOMS 4HESIGNSANDSYMPTOMSOFSCHISTOSOMIASISBILHARZIASIS VARYACCORDING TO THE SPECIES AND THE DURATION OF THE DISEASE THOUGH ALL ARE DIRECTLY OR INDIRECTLY A CONSEQUENCE OF MANS IMMUNE RESPONSE TO THE PARASITES DIF FERENTSTAGES !CUTESCHISTOSOMIASIS !CUTE SCHISTOSOMIASIS IS CHARACTERISED BY A TOXAEMIC PHASE INCLUDING FEVER DIARRHOEA EXHAUSTIONANDOTHERNON SPECIFICSYMPTOMS@+ATAYAMA SYNDROME AS A RESULT OF PASSAGE OF THE LARVAE OF 3 JAPONICUM THROUGH THELUNGANDTHEIRRAPIDGROWTHIMMUNERESPONSETOMETABOLICPRODUCTS INTHEMESENTERICVEINS&ORMATIONOFLARGEGRANULOMAS&IG ISFOUND AROUNDEGGSTHATAREDEPOSITEDINTHECAPILLARIESPARTICULARLYLIVER INTES TINE BLADDER  ,EUKOCYTOSIS WITH MARKED EOSINOPHILIA )N MILD INFECTIONS ANDALSOINTOURISTS EARLYSYMPTOMSEITHERDONOTOCCURORREMAINUNREC OGNISED

#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



#HRONICSCHISTOSOMIASIS !LL SYMPTOMS ARE A DIRECT OR INDIRECT CONSEQUENCE OF THE GRANULOMATOUS REACTIONTOTHEPARASITEEGGS&IGSAND 4HOUGHTHEGRANULOMASARE SMALLERINTHECHRONICSTAGETHANINTHEACUTESTAGEIMMUNOMODULATION THEQUANTITYOFEGGSIE OFWORMPAIRS ANDTHEDURATIONOFTHEINFECTION MANY YEARS OR EVEN LIFELONG WITHOUT TREATMENT DETERMINE THE COURSE OF THEDISEASE)NENDEMICAREAS BILHARZIASISISRELATIVELYRARELYFATALBUTOFTEN CAUSESINFIRMITY-ILDINFECTIONSARENOTTHREATENING!DISTINCTIONISMADE BETWEENURINARYANDINTESTINALSCHISTOSOMIASIS DEPENDINGONTHESITEOFTHE WORMSANDTHEORGANSINWHICHTHEEGGSAREDEPOSITED&IG  )NTESTINALSCHISTOSOMIASIS )NTESTINALSCHISTOSOMIASISISCAUSEDBYTHEEGGSOF3MANSONI 3JAPONICUM 3MEKONGIAND3INTERCALATUMTHATAREDEPOSITEDPRIMARILYINTHEINTESTINE AND THE LIVER &IG  OR ARE EXCRETED WITH THE STOOLS4HE GRANULOMATOUS INFLAMMATORY REACTION AROUND THE EGGS LEADS IN THE LARGE INTESTINE IN PAR TICULAR TO MUCOSAL HYPERAEMIA ULCERATION AND LATER ALSO GRANULOMATOUS PROLIFERATIONANDBLEEDING/FEVENGREATERSIGNIFICANCEWITHTHEFIRSTTWOOF THEAFOREMENTIONEDSPECIES HOWEVER ISTHATTHELIVERISDAMAGEDBYGRANU LOMAS THAT FORM AROUND EGGS THAT ARE CARRIED VIA THE BLOODSTREAM TO THE PRESINUSOIDAL BIFURCATIONS OF THE PORTAL VEIN #HRONIC PHLEBITIS PERIPORTAL FIBROSISANDFINALLY@PIPESTEMFIBROSISDEVELOPASARESULTOFTHEGRANULOMAS INTHELIVER%VENTHOUGHTHEPERIPORTALFIBROSISDOESNOTAFFECTTHEHEPATIC PARENCHYMABETWEENAREASOFFIBROSISANDDOESNOTINTERFEREWITHITSFUNC TIONING ITNEVERTHELESSLEADSTOPORTALHYPERTENSION#ONSEQUENCESOFTHIS MAY BE AS FOLLOWS FORMATION OF ASCITES PARTICULARLY WITH 3 JAPONICUM OESOPHAGEAL VARICES AND HEPATOSPLENOMEGALY7ORM EGGS MAY ULTIMATELY PASS VIA PORTOSYSTEMIC COLLATERALS INTO THE LUNG AND LEAD TO PULMONARY HYPERTENSIONANDCORPULMONALE4HESIGNSANDSYMPTOMSASSOCIATEDWITH INTESTINALSCHISTOSOMIASISRANGE FOREXAMPLE FROMEXHAUSTIONANDABDOMI NAL PAIN VIA DIARRHOEA WITH LOSS OF BLOOD AND PROTEIN THROUGH TO MASSIVE VARICEALBLEEDINGASACAUSEOFDEATH#HRONICINTESTINALSCHISTOSOMIASISPER SISTSFORYEARSANDITSSEVERITYDEPENDSONTHEINTENSITYANDDURATIONOFTHE INFESTATION/VERALL ITCONSTITUTESADISEASETHATISTRIGGEREDBYTHEIMMUNE RESPONSEINHUMANSTOTHEWORMEGGS

)MMUNERESPONSE 2ESPONSESINTHEHOSTTAKETHEFORMOFFORMATIONOF)G' )G! )G-AND)G% ACTIVATIONOFVARIOUSIMMUNOCOMPETENTCELLPOPULATIONSANDCIRCULATIONOF IMMUNECOMPLEXES4HEPARASITEPROTECTSITSELFBYMIMICRYOFHOSTPROTEIN AND BY PROTEASES THAT LEAD TO INACTIVATION OF ANTIBODIES AND COMPLEMENT FACTORS )MMUNE PROCESSES AT THE SCHISTOSOMULA STAGE MAY HOWEVER ALSO PROTECTAGAINSTRE INFECTIONANDSUPERINFECTION



!CHIM(ARDERAND(EINZ-EHLHORN

$IFFERENTIALDIAGNOSISANDDIAGNOSIS $IFFERENTIAL DIAGNOSES FOR BOTH INTESTINAL AND URINARY SCHISTOSOMIASIS ARE VARIOUSDISEASESOFOTHERORIGIN EG +ATAYAMASYNDROMENEEDSTOBEDISTIN GUISHEDFROMPARATYPHOIDFEVERANDTYPHOIDFEVER&URTHERMORE ANUMBER OFPARASITICANDOTHERINFECTIONSNEEDTOBEEXCLUDED BOTHINTHEACUTEAND THECHRONICPHASEOFTHEDIFFERENTFORMSOFSCHISTOSOMIASIS $IRECTDETECTIONINSMEARS SEDIMENTORAFTERCONCENTRATIONTAKESPLACE BYMEANSOFMICROSCOPICEXAMINATIONOFSTOOLSORURINEFORSCHISTOSOME EGGS THE SHAPE OF WHICH IS SPECIES SPECIFIC !  H URINE SPECIMEN OR SEVERALGRAMSOFSTOOLMAYBENECESSARYFORTHISPURPOSE3TOOLMAYCON TAIN THE EGGS OF 3 MANSONI n=n +M WITH LATERAL SPINE 3 INTERCALATUMn=n+M WITHTERMINALSPINE 3JAPONICUMn =n+M WITH A SMALL SIZED SPINE AND 3 MEKONGI n=n +M WITHASMALLSIZEDSPINE 1UANTITATIVEMETHODSMLURINEFILTRATE STOOL SMEAR USING THE +ATO +ATZ METHOD ARE EPIDEMIOLOGICALLY IMPOR TANT7HEREVERYFEWEGGSAREEXCRETED THEMIRACIDIUMHATCHINGTESTHAS PROVEDSUCCESSFUL4HISINVOLVESPLACINGTHEMIRACIDIAPRESENTINTHEEGGS INAFLASKTOHATCH"ECAUSEOFTHEIRPOSITIVEPHOTOTAXIS THESETHENMIGRATE INTOANILLUMINATED ATTACHEDSIDE ARMOFTHEFLASK FROMWHICHTHEYCAN BEREMOVED $ETECTION OF ANTISCHISTOSOMAL ANTIBODIES IN THE SERUM BY INDIRECT IMMUNOFLUORESCENCE INDIRECT HAEMAGGLUTINATION ANDOR %,)3! !LL TESTS AREGENERALLYBASEDONANTIGENPREPARATIONSWORMSOREGGS OF3MANSONI AND CROSS REACT WITH OTHER 3CHISTOSOMA SPECIES %VALUATION OF TITRE STEPS AND POSSIBLE CROSS REACTIONS WITH OTHER PARASITOSES SHOULD BE PERFORMED BY INSTITUTES OF PARASITOLOGY OR TROPICAL MEDICINE 4ESTS FOR CIRCULATING 3CHISTOSOMA ANTIGENS IN SERUM ARE LIKEWISE SUITABLE FOR THE DETECTION OF SCHISTOSOMIASIS

4REATMENT 0RAZIQUANTEL "ILTRICIDEš IS THE DRUG OF CHOICE AGAINST ALL 3CHISTOSOMA SPECIES4HEDOSAGEISXMGKGBODYWEIGHT"7 3JAPONICUM OR =MGKG"7ALLOTHERSPECIES ADMINISTEREDORALLYINONEDAY3IDE EFFECTS IFTHEYOCCURATALL AREONLYMINORPOSSIBLEEXCEPTIONSMASSIVE INFECTIONS AND CEREBRAL SCHISTOSOMIASIS  -ETRIFONATE "ILARZILš AND OXAMNIQUINE -ANSILš ARE ALSO USED IN SOME ENDEMIC AREAS ALTHOUGH THESE ARE EFFECTIVE ONLY AGAINST 3 HAEMATOBIUM AND 3 MANSONI RESPEC TIVELY

#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



2ESISTANCE 4HE EFFICACY OF PRAZIQUANTEL AGAINST 3 MANSONI IS REDUCED TO A VARYING DEGREEINDIFFERENT!FRICANCOUNTRIESASARESULTOFDEVELOPMENTOFWRONG USE4RUERESISTANCEHASNOTYETBEENSHOWN

0REVENTION !VOIDANCE OF SKIN CONTACT WITH CONTAMINATED WATERS RELIABLY PROTECTS AGAINSTINFECTION/THERPROPHYLACTICMEASURESVACCINATION CHEMOPROPHY LAXIS ARENOTAVAILABLE

3TRATEGIESFORDISEASEPREVENTIONANDCONTROL )NDIVIDUAL PROPHYLAXIS INVOLVES AVOIDANCE OF SKIN CONTACT WITH CONTAMI NATEDWATERSRIVERS LAKES PONDS RICEFIELDS IRRIGATIONSYSTEMS  )NHIGHLYENDEMICAREAS MASSTREATMENTORSELECTIVETREATMENTOFINFECT ED PERSONS WITH PRAZIQUANTEL IS INDICATED IN ADDITION TO HEALTH EDUCATION MEASURESANDPROPERDISPOSALOFHUMANEXCREMENT5SEOFMOLLUSCICIDESFOR INTERMEDIATEHOSTCONTROLISPOSSIBLEONLYINLIMITEDAREAS

(EPATITISCAUSEDBYNEMATODES #APILLARIASIS#APILLARIAHEPATICA; = /THERNAMEOFTHEAGENTOFDISEASE .OOTHERSPECIFICNAMEDISEASEHEPATICCAPILLARIASIS

4AXONOMY 3UBREGNUM 0HYLUM #LASS 3UBCLASS /RDER &AMILY 'ENUS

!NIMALIA .EMATOZOA .EMATODES !DENOPHOREA 4RICHOCEPHALIDA #APILLARIDAE #APILLARIA

-ORPHOLOGY 4HE PATHOGEN IS #APILLARIA HEPATICA A NEMATODE AS SLENDER AS A HUMAN

210

Achim Harder and Heinz Mehlhorn

Figure 30. Light micrograph of a section showing a layer of eggs in the liver

hair, measuring up to approximately 10 cm in length in the adult stage, with marked hepatotropism.

Epidemiology The parasite is prevalent worldwide and its principal hosts are rodents, predominantly rats, in which prevalence rates may be as high as 80% or more. Infection in humans is rare. Approximately 40 confirmed cases, in total, have been reported in North and South America, Africa, Asia and Central Europe, although it is likely that a number of cases remained unreported.

Transmission, multiplication and incubation period Humans are infected by oral ingestion of the parasite’s embryonated (larvacontaining) eggs.

#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



#HEPATICAPARASITISESTHEHEPATICPARENCHYMAWITHINWHICHITMIGRATES !T THE SAME TIME THE ADULT FEMALE WORMS LAY CHARACTERISTIC EGGS WITH  POLARPLUGS&IG 4HEEGGS WHICHAREDEPOSITEDINTHEBOREHOLESANDARE LATERENCAPSULATEDINTUBULARGRANULOMAS REACHTHEOUTSIDEWORLDONLYBY MEANSOFMACERATIONONTHEDEATHOFTHEHOSTOR IFINFECTEDANIMALSSERVED ASPREY VIATHEDIGESTIVETRACTOFTHEPREDATORCANNIBALISMALSOPLAYSAROLE IN THE CASE OF RATS  /NCE IN THE OPEN AN INFECTIVE LARVAL STAGE DEVELOPS INSIDETHEEGGANDTHISISTHENINGESTEDBYHUMANSWITHCONTAMINATEDFOOD 4HELARVAHATCHESFROMTHEEGGMEMBRANEINTHEINTESTINE MIGRATESTHROUGH THEINTESTINALWALLANDPASSESVIATHEBLOODSTREAMTOTHELIVER3EXUALMATU RITY AND HENCE COMMENCEMENT OF EGG LAYING ARE ATTAINED AFTER n WEEKS PREPATENTPERIOD 

$ISEASESANDSYMPTOMS 4HERE ARE ONLY RARE CASES OF DISEASE CAUSED BY SINGLE FEW LIVER SPECIFIC ROUNDWORMS WHILE SERIOUS CONSEQUENCES OCCUR IN THE EVENT OF MASSIVE INFECTIONS 4HE CLINICAL PRESENTATION DEPENDS ON THE BURDEN OF INFECTION ,IGHT INFECTION OCCASIONALLY REPORTED AS A POST MORTEM FINDING WOULD APPEAR TO BE ASYMPTOMATIC )N HEAVY INFECTIONS WHICH IN CHILDREN MAY PROVE FATAL AN ACUTE COURSE IS TO BE EXPECTED AT AROUND THE COMMENCEMENT OF EGG LAYING THESE SYMPTOMS REFLECTING THE DESTRUCTION OF LARGE AREAS OF LIVER PARENCHYMA )N SUCH CASES UNEXPLAINED EXTRAHEPATIC SYMPTOMS EG LUNGDISORDERS HAVEBEENDESCRIBEDINTHEPATHOGENESIS-ODERATE INFECTIONSAREASSOCIATEDWITHUNCHARACTERISTICUPPERABDOMINALPAINAND HEPATOMEGALY,EUCOCYTOSIS EOSINOPHILIAANDHYPERGAMMAGLOBULINAEMIA REGULARLYOCCUR

$IFFERENTIALDIAGNOSISANDDIAGNOSIS &OCAL OR DISSEMINATED DAMAGE TO THE LIVER PARENCHYMA OF DIVERSE ORIGIN 7ORMNODULESWITHCONVOLUTEDPARASITESANDOREGGSTRINGSENCAPSULATEDIN GRANULOMASAREOFTENTOBEFOUNDINTHESUBCAPSULARREGIONANDARELAPA ROSCOPICALLYDETECTABLE)NPATENTINFECTIONS THEDIAGNOSISCANBECONFIRMED BYBIOPSY REVEALINGEGGSMEASURING=+MWITHPOLARPLUGS&IG  4HEREARENOSEROLOGICALMETHODSAVAILABLE

4REATMENT -EBENDAZOLEISEFFECTIVEACCORDINGTOFINDINGSINANIMALEXPERIMENTS



!CHIM(ARDERAND(EINZ-EHLHORN

0ROPHYLAXIS !VOID CONTAMINATED FOODS KEEP CHILDREN AWAY FROM AREAS POPULATED BY RATS

,ARVAMIGRANSDISEASE-IGRATINGNEMATODES; = -IGRATING LARVAE OR ADULTS OFTEN PASS VIA THE BLOODSTREAM FROM THE INTES TINETOTHELIVER4HESEPARASITESHAVELEFTTHEINTESTINEANDAREENROUTETO OBLIGATORYPASSAGETHROUGHTHEHEARTANDLUNGS DURINGWHICHTHEYMAYBE CARRIEDOFFVIATHEBLOODSTREAMTOOTHERORGANS)FTHELARVAEAREUNABLETO REACHSEXUALMATURITYINHUMANS MIGRATIONCONTINUESUNTILTHEIRDEATHn MONTHS 4HEFOLLOWINGNEMATODESHAVEBEENDETECTEDQUITECOMMONLYIN THELIVERLARVAMIGRANSVISCERALIS 

!SCARISLUMBRICOIDES,LARVAANDADULT

3TRONGYLOIDESSTERCORALISLARVAE

(OOKWORMLARVAE&IG

4OXOCARACANISLARVAE

-ICROFILARIAEOFVARIOUSFILARIAE&IG

4REATMENT !FTER INVASION INTO THE BILIARY SYSTEM ENDOSCOPIC EXTRACTION OF ! LUM BRICOIDES LARVAE CAN BE TRIED BEFORE SURGICAL INTERVENTION &OR REMOVAL OF 3TRONGYLOIDESSTERCORALISLARVAE THEBENZIMIDAZOLESALBENDAZOLE THIABEN DAZOLEORMEBENDAZOLECANBEAPPLIED!LSOTHEMACROCYCLICLACTONESEEMS TO BE EFFECTIVE !GAINST HOOKWORM LARVAE MEBENDAZOLE AND ALBENDAZOLE MAYBEUSED&ORINFECTIONSWITH4OXOCARACANISLARVAE THIABENDAZOLE XMGKGBODYWEIGHTDAILYOVERnDAYS ALBENDAZOLEMGKGBODY WEIGHTOVERDAYS ORDIETHYLCARBAMAZINEARERECOMMENDED-ICROFILARIAE OFVARIOUSFILARIAECANBETREATEDWITHDIETHYLCARBAMAZINEWITHATOTALORAL DOSEOFMGKGBODYWEIGHTGIVENOVERnWEEKS!LSOIVERMECTINATA SINGLESUBCUTANEOUSDOSEOFMGKGBODYWEIGHTMAYBETRIED

0ENTASTOMIDIASIS0ENTASTOMIDA; = /THERNAMESOFTHEAGENTSOFDISEASE 4ONGUEWORMS ,INGUATULIDAE

#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



4AXONOMY 0HYLUM #LASS /RDER &AMILY 'ENUS

0ENTASTOMIDA 0ENTASTOMIDEA 0OROCEPHALIDA !RMILLIFERIDAE !RMILLIFER ,INGUATULA 0OROCEPHALUS

"IOLOGYMORPHOLOGY 4HEADULTSOFTHEGENERA,INGUATULA !RMILLIFERAND0OROCEPHALUSLIVEINTHE NASOPHARYNXANDLUNGSOFCARNIVOROUSVERTEBRATES,INGUATULASERRATAALSO INHUMANS &IGSAND ,SERRATAFEMALESAREUPTOCMLONG MALES UPTOCMLONGANDAREFOUNDMAINLYINDOGS!RMILLIFERSPECIESREACHASIM ILARSIZE 0OROCEPHALUSSPECIESARENOTMORETHANCMLONG4HEEGGS WHICH MEASURE ABOUT = +M ,INGUATULA OR  +M IN LENGTH !RMILLIFER LEAVETHEBODYWITHTHENASALMUCUSATTHETIMEOFSHEDDINGTHEYALREADY CONTAIN A FIRST STAGE LARVA )F THESE EGGS ARE INGESTED BY HERBIVORES OR BY HUMANS THE LARVAE PENETRATE THE GUT WALL AND MIGRATE TO VARIOUS ORGANS INCLUDING LIVER LUNG WHERE THEY UNDERGO SEVERAL MOULTS AND GROW TO A SIZE OF n MM ,INGUATULA SERRATA OR n MM !RMILLIFER ARMILLATUS  )F THIS INTERMEDIATE HOST IS EATEN BY A CARNIVORE THE LARVAE BECOME SEXUALLY MATUREINITSNASOPHARYNXAFTERUNDERGOINGAFURTHERMOULTANDTHEFEMALES BEGINTOLAYTHESOMETIMESPRODIGIOUSNUMBERSOFEGGSASMANYAS  PERDAY 

4RANSMISSION MULTIPLICATIONANDINCUBATIONPERIOD 4HEREAREVARIOUSROUTESOFINFECTIONINMAN(UMANSLIKEHERBIVORES CAN BECOME INFECTED BY INGESTING EGGS CONTAINING LARVAE WITH THEIR FOOD4HE LARVAE THEN HATCH AND MIGRATE THROUGH THE BODY OFTEN INVADING THE LUNG ANDLIVER4HISROUTEOFINFECTIONPLAYSAPARTICULARROLEIN!FRICANAND!SIAN COUNTRIES AS IN THESE COUNTRIES HUMANS RELATIVELY OFTEN BECOME INFECTED WITH EGGS OF PENTASTOMES OF THE GENERA !RMILLIFER AND 0OROCEPHALUS THE DEFINITIVE HOSTS OF WHICH ARE SNAKES WHEN HANDLING SNAKES AND CONTAMI NATEDPLANTSORPREPARINGTHEMFORCOOKING ANDTHENBECOMETHEINTERMEDI ATEHOST"YINGESTIONOFLARVAEWITHINSUFFICIENTLYCOOKEDORRAWMEATFROM INFECTEDINTERMEDIATEHOSTS)NTHECASEOF,SERRATATHESECANEVENBECOME SEXUALLYMATUREINTHENASOPHARYNX )NCUBATIONPERIOD $EPENDS ON THE STAGE OF INFECTION !FTER CONSUMPTION OF LARVA INFECTED MEATTHEPRE ADULTWORMSLEADTOLOCALREACTIONSWITHINAFEWDAYS)FTISSUE



!CHIM(ARDERAND(EINZ-EHLHORN

STAGESOCCURITCANBEnMONTHSBEFORETHEMIGRATINGLARVAECAUSEDAMAGE ANDSYMPTOMS 0REPATENTPERIOD nMONTHSINTHECASEOF,INGUATULA 0ATENTPERIOD MONTHSINTHECASEOF,INGUATULA RARELYLONGER

%PIDEMIOLOGY ,INGUATULA SERRATA OCCURS WORLDWIDE SPECIES OF THE GENERA !RMILLIFER AND 0OROCEPHALUSAREFOUNDIN!FRICAAND!SIA

$ISEASESANDSYMPTOMS 4HE FOLLOWING SYMPTOMS CAN OCCUR DEPENDING ON WHETHER THE PERSON IS INFECTEDASANINTERMEDIATEORDEFINITIVEHOST-OSTINFECTIONSOCCURINTHE NASALREGIONBYADULTSOF,SERRATAANDLEADTOTHESYNDROMEKNOWNASHAL ZOUN4HENASALPASSAGESCANBECOMECOMPLETELYBLOCKED)NADDITIONTHERE ISDEAFNESSANDFACIALSWELLING)FTHEREISPRONOUNCEDSNEEZINGTHESEADULTS CANBEEXPELLEDSPONTANEOUSLY )NFECTIONOFTHEABDOMINALORGANS AMONGTHEMTHELIVERBY!RMILLIFER ARMILLATUS WITHTHESOMETIMESVERYLARGELARVAELEADSTOUNSPECIFICSYMP TOMS CAUSED BY THE BORING ACTIVITY OF THE MIGRATING LARVAE $EPENDING ON THELOCATIONOFTHEDAMAGETHISCANLEADTOTHEDEATHOFTHEINFECTEDPERSON ASHASBEENOBSERVEDINNUMEROUSAUTOPSIESIN!FRICA

$IFFERENTIALDIAGNOSISANDDIAGNOSIS -ICROSCOPICDETECTIONOFTHEEGGSINNASALSECRETIONSORFINDINGOFSPONTA NEOUSLYPASSEDWORMSINTHECASEOF,INGUATULA(ISTOLOGICALDETECTIONOF LARVAELOCATEDINTHETISSUES$IFFERENTIATIONFROMOTHERWORMEGGS

0ROPHYLAXIS !VOIDINGTOUCHINGSNAKESANDDOGSORTHEIRFAECES PARTICULARLYINSUBTROPI CALANDTROPICALREGIONS!VOIDINGINFECTIONOFONESELFANDOFONESDOGBY EATINGONLYCOOKEDMEAT4RAININGDOGSNOTTOEATRODENTS

#OMPARATIVEHEPATITIS$ISEASESCAUSEDBYADULTPARASITESx



4REATMENT 5NKNOWN7ORMS IN THE NASAL REGION CAN BE REMOVED BY PROVOCATION OF SNEEZINGORBYSURGICALPROCEDURES

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!BSTRACT !UTOIMMUNEHEPATITIS!)( CANOCCURINALLAGEGROUPSFROMEARLIESTCHILDHOODUPUNTIL THETHDECADE!)(AFFECTSWOMENMORECOMMONLYTHANMEN #LINICALPRESENTATION MAYBEANACUTEHEPATITISUPTOFULMINANTLIVERFAILURE BUTCANALSOBEASYMPTOMATIC !)( IS CHARACTERISED BY LYMPHO PLASMACELLULAR INFILTRATES ON LIVER BIOPSY ELEVATED LIVERENZYMESINSERUMANDASSOCIATIONWITHTHE(,!HAPLOTYPES" $2AND$2IN THE ABSENCE OF ACTIVE VIRAL MARKERS 0ATIENTS CHARACTERISTICALLY PRESENT WITH HYPERGAM MAGLOBULINEMIA ELEVATED SERUM LEVELS OF )G' AND AUTOANTIBODIES SUCH AS ANTINUCLEAR ANTIBODIES!.! SMOOTHMUSCLEANTIBODIES3-! ANTIBODIESTOSOLUBLELIVERANTIGEN LIVERPANCREAS3,!,0 ORTOLIVER KIDNEYMICROSOMES,+-  #ORTICOSTEROIDSARETHEDRUGOFCHOICEFORREMISSIONINDUCTION AZATHIOPRINETHEDRUG OFCHOICEFORMAINTENANCEOFREMISSION4HERAPIDRESPONSETOIMMUNOSUPPRESSIVETREAT MENTSUPPORTSTHEDIAGNOSISOF!)(ANDLEADSTOAGOODLONG TERMPROGNOSIS4REATMENT DURATIONREMAINSCONTROVERSIALANDCANBEDISCUSSEDAFTERRESOLUTIONOFALLCLINICAL LABO RATORYANDHISTOLOGICALMANIFESTATIONSOFDISEASEACTIVITY4REATMENTSHOULDBEMAINTAINED FORAMINIMUMOFYEARS

!GENT !UTOIMMUNE HEPATITIS !)( IS A CHRONIC INFLAMMATORY DISORDER OF THE LIVER OF UNKNOWN ORIGIN ASSOCIATED WITH HYPERGAMMAGLOBULINAEMIA AND THEOCCURRENCEOFAUTOANTIBODIES; =!SINOTHERAUTOIMMUNEDISORDERS AGENETICPREDISPOSITIONOFTHEHOSTSUCHASTHEPRESENCEOF(,!#LASS)" AND(,!#LASS))$2 $2AND$2AHASBEENFOUND;=)NADDITION UNKNOWNENVIRONMENTALTRIGGERSSUCHASVIRALORBACTERIALINFECTIONORDRUGS MAYTHENINDUCEAUTOIMMUNEHEPATITISINTHEGENETICALLYPREDISPOSEDHOST 4HE LOSS OF IMMUNE TOLERANCE TO SELF ANTIGENS MAY BE DUE TO THE RELEASE OFMODIFIEDANDPRIMARILYSEQUESTEREDNUCLEARORCYTOSOLICPROTEINSWHICH ACTIVATE RESTING BUT NATURALLY OCCURRING AUTO REACTIVE4 CELLS &OR EXAMPLE HEPATITIS # VIRUS HAS THE POTENTIAL TO INDUCE SUCH AUTO REACTIVE 4 CELLS THAT CROSS REACTIVELY RECOGNISE THE CYTOCHROME 0 ISOFORMS ! AND



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! WHICH CONTAIN SEQUENCE HOMOLOGY TO (#6 ;= 4HIS CROSS REACTIVITY BETWEEN FOREIGN AND SELF PROTEINS IS COMMONLY REFERRED TO AS @MOLECULAR MIMICRY 5P TO  OF PATIENTS WITH CHRONIC (#6 INFECTION DISPLAY AUTOANTIBODIES DIRECTED AGAINST THE CYTOCHROME 0 $ #90$ ;= (OWEVER AUTOIMMUNE HEPATITIS IS ONLY EXTREMELY RARELY ASSOCIATED WITH VIRAL HEPATITIS 4HE #90$ HUMANISED MOUSE MODEL OF !)( EXPRESSES THIS HUMAN ANTIGEN IN THE LIVER AND SHOWS PERSISTENT HEPATITIS AFTER INFEC TIONWITHAN!DENOVIRUS #90$VECTOR; =-OSTOTHERANIMALMODELS OF!)(USEDTRANSGENICTARGETANTIGENSEXPRESSEDINTHELIVERBUTCOULDONLY DEMONSTRATETRANSIENTHEPATITIS;n= 4HEPRINCIPALEFFECTORCELLSOF!)(ARE#$AND#$LYMPHOCYTES MAINLY FOUND IN THE PORTAL TRACTS AND #$4 LYMPHOCYTES MAINLY FOUND PERIPORTALLY;=4HEREPERTOIREOFANTIGENSTHATSENSITISETHESECELLSSEEMS RESTRICTED )NFILTRATING #$ LYMPHOCYTES SHOW DEFECTS IN THEIR APOPTOTIC PATHWAYWHICHMIGHTBERESPONSIBLEFORTHEPERPETUATIONOFINFLAMMATION ;=#O STIMULATORYMOLECULESLIKE#$AREUPREGULATEDONLIVER INFILTRAT INGMONOCYTESIN!)(PATIENTSBUTNOTINPATIENTSWITHCHRONIC(#6INFEC TION;=2EGULATORY#$#$LYMPHOCYTESHAVEBEENSHOWNTOINHIBIT #$4 CELLPROLIFERATIONANDAREDECREASEDINNUMBERANDFUNCTIONIN!)( PATIENTS;=)THASBEENSPECULATEDTHAT!)(CANBETRIGGEREDBYCERTAIN DRUGS!RECENTREPORTASSOCIATEDSTATINSUSEDINTHETREATMENTOFHYPERCHO LESTERINEMIAWITHTHEONSETOF!)(;=!LTHOUGHTHEEXACTPATHOGENESIS ISNOTUNDERSTOODYET DIAGNOSING!)(ANDPROVIDINGADEQUATETREATMENTIS EXTREMELYIMPORTANTFORTHEPATIENTSAFFECTEDBYTHEDISEASE !)( WAS THE FIRST LIVER DISEASE IN WHICH CONTROLLED TRIALS PROVED THE EFFICACYOFATHERAPEUTICINTERVENTIONCORTICOSTEROIDS ANDINWHICHTIMELY DIAGNOSISANDADEQUATETHERAPYISLIFE SAVINGANDCANREVERSEDISEASEPRO GRESSIONTOLIVERCIRRHOSISRESULTINGINANORMALLIFEEXPECTANCYINTHEMAJOR ITYOFTREATEDPATIENTS;=

%PIDEMIOLOGY 4HEPREVALENCEOF!)(ISESTIMATEDAROUND n ;=!)(CAN MANIFESTATANYAGEFROMVERYEARLYCHILDHOODUPUNTILTHETHDECADEAND LIKEMANYOTHERAUTOIMMUNEDISEASESITISMORECOMMONINWOMENGENDER RATIO  /VEROFTHEPATIENTSDEVELOP!)(AFTERTHEAGEOFYEARS ;=!SMANYASOFTHEPATIENTSPRESENTSUBCLINICALLY; =LEADINGTO DELAYEDDIAGNOSIS4HISDELAYEXPLAINSTHATMANYPATIENTSALREADYSHOWCIR RHOSISATPRESENTATION; =5PTOONETHIRDOFPATIENTSMAYPRESENTWITH AVERYACUTEDISEASEANDSOMEEVENWITHFULMINANTHEPATICFAILURE THEREFORE !)(MUSTBECONSIDEREDINALLPATIENTSWITHAFULMINANTPRESENTATION;= !UTOIMMUNEHEPATITISCANBEASSOCIATEDWITHCONCURRENTIMMUNEDISEASES SUCHASSYSTEMICSCLEROSISANDPOLYMYOSITIS;= MULTIPLEXNEURITIS;= AND POLYGLANDULARAUTOIMMUNESYNDROMETYPE)));=

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4REATMENT )MMUNOSUPPRESSION DRAMATICALLY IMPROVES THE OUTCOME IN AUTOIMMUNE HEPATITIS AND WITH INDIVIDUALISED IMMUNOSUPPRESSION PATIENTS CAN LOOK FORWARD TO A NORMAL LIFE EXPECTANCY AND GOOD QUALITY OF LIFE4HE PROMPT RESPONSE TO CORTICOSTEROIDS CAN BE OBSERVED IN NEARLY ALL !)( PATIENTS WHICH MAKES IT THE MOST RELIABLE FINAL DIAGNOSTIC TOOL NON RESPONSE TO IMMUNOSUPPRESSION SUGGESTS ANOTHER DIAGNOSIS PROVIDED THE PATIENT IS COMPLIANT AND THE DOSE IS ADEQUATE #ORTICOSTEROID TREATMENT IS JUSTIFIED EVEN IN ASYMPTOMATIC PATIENTS SINCE THESE PATIENTS WILL USUALLY DEVELOP SYMPTOMS;=4HEPREFERREDTREATMENTSCHEDULEINADULTSISPREDNISOLONE COMBINEDWITHAZATHIOPRINE

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PRESSION MAY COME TOO LATE FOR SOME OF THESE PATIENTS AND THE STANDARD CRITERIAFOREMERGENCYLIVERTRANSPLANTATIONSHOULDBEUSEDFORTHEPATIENTS ASWELL DESPITETHEPRESENCEOFANUNDERLYINGCONDITIONWHICHINPRINCIPLE IS VERY RESPONSIVE TO TREATMENT 3OME PATIENTS RAPIDLY DETERIORATE ON STE ROIDS IN THIS SITUATION AND ANY DELAY IN TRANSPLANTATION WILL INCREASE THE RISK OF POTENTIALLY FATAL INFECTION 0ATIENTS WITHOUT ENCEPHALOPATHY HOW EVER SHOULDUNDERGOANINTENSIVETRIALOFIMMUNOSUPPRESSION GIVINGUPTO MGPREDNISOLONEIVFORTHEFIRSTFEWDAYS !FTER TRANSPLANTATION MORE INTENSIVE IMMMUNOSUPPRESSION INCLUDING AZATHIOPRINE IS RECOMMENDED AS RELAPSE OF!)( IS RECOGNISED IN AT LEAST nOFTRANSPLANTEDPATIENTSWITHINYEARS;=

0ATIENTSINTOLERANTOFAZATHIOPRINE )NTOLERANCE TO AZATHIOPRINE CAN BE OBSERVED IN UP TO  OF THE PATIENTS ANDASIMILARPROPORTIONOFADDITIONALPATIENTSWILLDEVELOPSIDEEFFECTSLATER ON MOSTLYDUETOARTHRALGIA LYMPHOPENIA MYELOSUPPRESSION  HEPATOTOXICITY OR PANCREATITIS REQUIRING EITHER DOSE REDUCTION OR COMPLETE DRUG WITHDRAWAL7HILE SOME OF THESE PATIENTS CAN BE MANAGED WITH STEROID MONOTHERAPY THE MAJORITY WILL REQUIRE ANOTHER SECOND LINE DRUG0RIMARILYBECAUSEOFITSLOWTOXICITY MYCOPHENOLATEMOFETILNOWHAS EMERGEDASTHESTANDARDSECONDCHOICEDRUGFORTHESEPATIENTS4HREESMALL CLINICALSTUDIESPROVIDEDEVIDENCETHATABOUTTWOTHIRDSOFPATIENTSFAREWELL ON--&ATADOSEOF MGTWICEDAILY;= WHILEONETHIRDAPPEARSTO NOTREALLYBENEFITFROMTHEDRUG)NTHESEFEWPATIENTSTHECHOICEBECOMES MORE DIFFICULT /UR PERSONAL PREFERENCE IN DESCENDING ORDER IS CYCLO PHOSPHAMIDE METHOTREXATE OR CYCLOSPORINE #YCLOPHOSPHAMIDE CAN BE GIVENORALLYMGDAYINITIALLY ORASABOLUSINFUSIONLIKEIN3,%4HESE PATIENTS HOWEVER SHOULD BE TREATED IN SPECIALISED CENTRES AS SIDE EFFECTS OFTHEDRUGNEEDTOBECLOSELYWEIGHEDAGAINSTTHEDANGERSOFPROGRESSIVE DISEASE

0OORRESPONDERSTOSTANDARDIMMUNOSUPPRESSION $ESPITEUSINGTHESCHEDULEOFHIGHDOSESTEROIDSINTHEINITIATIONOFTREAT MENT ABOUTOFTHEPATIENTSHAVEWORSENINGAMINOTRANSFERASESORBILI RUBINLEVELSINDICATINGTOFAILREMISSION;=)NSOMEOFTHESEHIGHERTHAN USUAL MAINTENANCE DOSES n MG PREDNISOLONEDAY UP TO  MGKGDAY AZATHIOPRINE MAY BE THE BEST CHOICE OF MANAGEMENT /NLY EXCEPTIONAL PATIENTSWILLCONTINUETOSHOWHIGHINFLAMMATORYACTIVITYAFTERINTENSIFYING IMMUNOSUPPRESSION)NTHESEPATIENTS TREATMENTFAILUREWARRANTSREASSESS MENTWITHREGARDTOTHEACCURACYOFTHEDIAGNOSISANDEXCLUSIONOFVARIANT SYNDROMES OR OTHER HEPATIC DISEASES EG DRUG INDUCED HEPATOTOXICITY A

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AUTOIMMUNE HEPATITIS AND PRIMARY SCLEROSING CHOLANGITIS * (EPATOL  n   ,OHSE!7 ZUM"USCHENFELDE+( &RANZ" +ANZLER3 'ERKEN' $IENES(0  #HARACTERIZATION OF THE OVERLAP SYNDROME OF PRIMARY BILIARY CIRRHOSIS 0"# ANDAUTOIMMUNEHEPATITISEVIDENCEFORITBEINGAHEPATITICFORMOF0"# INGENETICALLYSUSCEPTIBLEINDIVIDUALS(EPATOLOGYn

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!BSTRACT ,IVERDISEASESAREAMAJORFOCUSOFRESEARCHINTHE&ACULTYOF6ETERINARY-EDICINE)NA CLINICALPOPULATIONOFTHEDOGSHASAFORMOFHEPATITIS4HEREARESEVERALASPECTSOF CANINEHEPATITISWHICHMAKECOMPARISONWITHHUMANHEPATITISVERYUSEFUL!SAWHOLE LIVERDISEASESANDESPECIALLYDIFFERENTFORMSOFHEPATITISINDOGSDEVELOPHIGHLYSIMILARTO HUMANHEPATITISFULMINANT ACUTE CHRONIC 4HISMAKESDOGDISEASESINTERESTINGTOSTUDY IMPORTANT ASPECTS IN THE PATHOGENESIS OF THE DISEASE 7E HAVE SHOWN THAT IN HUMANS AND DOGS IDENTICAL PROCESSES WITH RESPECT TO FORMATION OF FIBROSIS REGENERATION STEM CELLACTIVATION ANDOXIDATIVEDAMAGEOCCUR)NMOSTASPECTSIDENTICALPATHOGENESISAND PATHOPHYSIOLOGY OF CANINE AND HUMAN HEPATITIS MAKE THESE SPONTANEOUS DOG DISEASES IDEALMODELSTOSTUDYTHEEFFECTOFNEWMODESOFINTERVENTIONTOSTIMULATEREGENERATION ANDREDUCEORPREVENTCIRRHOSIS

)NTRODUCTION (EPATITISISAFREQUENTLIVERDISEASEINDOGS4HEPRIMARYINFLAMMATORYDIS EASEINDOGSAFFECTSTHEPARENCHYMEHEPATITIS WHICHISDIFFERENTFROMTHE SITUATIONINCATSWHEREITISPRIMARILYOFBILIARYORIGINCHOLANGITIS ;= &OLLOWINGDESTRUCTIONOFHEPATICPARENCHYMAAPOPTOSISORNECROSIS AN INFLAMMATORYREACTION REGENERATIONOFPARENCHYMA FIBROSIS ANDDUCTULAR PROLIFERATION MAY OCCUR7HEN HEPATOCYTIC DESTRUCTION IS LIMITED AND THE RETICULINNETWORKREMAINSINTACT REGENERATIONWITHCOMPLETERESTITUTIONOF THE LIVER STRUCTURE CAN OCCUR 3EVERE PARENCHYMAL DESTRUCTION WITH EXTEN SIVE LOSS OF HEPATOCYTES OFTEN IS FOLLOWED BY DUCTULAR PROLIFERATION -ANY OFTHESESTRUCTURESCONTAINBOTHLIVER CELLANDBILE DUCTELEMENTSANDMAY REFLECTREGENERATIVEPROLIFERATIONOFANHEPATICSTEMCELLPOPULATIONANALO GOUSTOOVALCELLSINTHERAT ORTRANSFORMATIONOFREGENERATINGHEPATOCYTES INTODUCTULAR LIKESTRUCTURES4HESESTRUCTURESGENERALLYAREMOSTPROMINENT INTHEPERIPORTALAREAS,IKEINMAN THESEARE#+ POSITIVELIVERPROGENITOR CELLS7ITH CHRONIC PARENCHYMAL DAMAGE OR EXTENSIVE LOSS OF HEPATOCYTES FIBROSISANDPOSTNECROTICSCARRINGMAYOCCURWITHTHEFORMATIONOFINTRAHE



*AN2OTHUIZEN

PATICPORTOVENOUSSHUNTSINTHESECASESPROLONGEDREGENERATIVEEFFORTWILL RESULTINREGENERATIVEPARENCHYMALNODULES 4HE DIAGNOSIS OF HEPATITIS AND ITS CLASSIFICATION ACUTE CHRONIC ETC IS ONLY POSSIBLE WITH HISTOLOGY OF THE LIVER4HE HISTOPATHOLOGIC DIAGNOSIS INCLUDES THE TYPE PATTERN AND EXTENT OF THE NECROSIS AND INFLAMMATION AND THE POSSIBLE CAUSE AND IN MORE CHRONIC CASES THE PRESENCE PATTERN ANDEXTENTOFFIBROSISANDREGENERATION4HEACTIVITYOFTHEINFLAMMATIONIS DEFINEDBYTHEAMOUNTOFHEPATOCELLULARNECROSISANDINFLAMMATION ANDTHE CHRONICITYISDETERMINEDBYTHEAMOUNTOFFIBROSIS &OR VETERINARY MEDICINE THERE IS A LIVER CONSENSUS GROUP OF THE7ORLD 3MALL !NIMAL 6ETERINARY !SSOCIATION 73!6!  4HIS GROUP HAS RECENTLY PUBLISHEDACONSENSUSFORTHENOMENCLATUREANDTHECLINICALANDHISTOLOGICAL DIAGNOSTIC CRITERIA IN THE DIAGNOSIS OF LIVER DISEASES ;=4HESE WORLD STAN DARDSANDTHEACCEPTEDNOMENCLATUREHASBEENUSEDINTHISCHAPTER

!CUTEHEPATITISINDOGS %TIOLOGY !CUTE HEPATITIS CAN BE CAUSED BY CHEMICALS THE MOST FAMILIAR ARE ORGAN IC SOLVENTS SUCH AS ##L AND PHOSPHOROUS VIRAL INFECTION ;= INFECTIOUS CANINEHEPATITISDUETOTHE#ANINE!DENOVIRUS;#!6 = ANDMYCOTOXINS ESPECIALLY AFLATOXIN "  !CUTE HEPATITIS MAY ALSO BE CAUSED BY VARIOUS TOXINS SUCH AS MUSHROOM TOXINS !MANITUM OR BLUE GREEN ALGAE TOXINS #YANOPHYCEAE $RUGSALSOMAYCAUSEACUTEHEPATITISINDOGS$RUG INDUCED HEPATITIS HAS BEEN REPORTED AFTER TREATMENT WITH NALIDIXINE ACID ; = !DDITIONAL FORMS OF DRUG INDUCED HEPATITIS IN DOGS HAVE BEEN REPORTED IN DOGSLIKEIDIOSYNCRATICDRUGTOXICITYSULFONAMIDES CARPROFEN ANDAMIODA RONE ORDOSE DEPENDENTDRUGTOXICITYACETAMINOPHEN ; =#!6 IS SO FAR THEONLYKNOWNHEPATITISVIRUSINDOGS BUTTHESIMILARITYOFFORMSOFACUTE ANDCHRONICHEPATITISBETWEENDOGSANDMANINDICATESTHAT LIKEINMAN THERE MAYBEMOREHEPATITISVIRUSESINIDIOPATHICCASESOFCANINEHEPATITIS4HERE ARETHREEFORMSOF#!6  CAUSEDHEPATITIS PERACUTE ACUTEANDCHRONIC (EPATITIS RESULTING FROM SEPSIS NON SPECIFIC REACTIVE HEPATITIS AND HYPOXIAHAEMOLYSIS SHOCK ARENOTDISCUSSEDHERE

0ATHOGENESISANDPATHOLOGY $EPENDINGONTHEEXTENTOFTHELIVERCELLNECROSIS INTRACELLULARENZYMESWILL BE RELEASED AND BILE WILL LEAK BACK INTO THE CIRCULATION )N ACUTE HEPATITIS ALL OF THE ENZYMES !,4 !34 AND BILE ACIDS ARE USUALLY HIGHLY ELEVATED &EVERCAN BUTDOESNOTALWAYS OCCURASARESULTOFPYROGENSFROMNECROTIC TISSUEANDFROMREDUCEDREMOVALOFENDOTOXINSANDBACTERIAFROMTHEPORTAL

(EPATITISINDOGS



BLOOD$IFFUSEINTRAVASCULARCOAGULATIONISOFTENSEEN6ERYEXTENSIVELIVER CELLNECROSISWITHLOSSOFAGREATAMOUNTOFLIVERFUNCTIONFULMINANTHEPA TITIS SEEMSTOBEQUITERARE BUTMAYBEMISSEDBECAUSESUCHCASESMAYNOT REACHREFERRALCENTRES)TLEADSTOTHEDEVELOPMENTOFHEPATICENCEPHALOPA THY DISSEMINATEDINTRAVASCULARCOAGULOPATHIA$)# JAUNDICE ANDHYPOGLY CAEMIAVIALOSSOFGLYCOGENSYNTHESISANDGLYCONEOGENESIS4HISSEVEREFORM PROGRESSESRAPIDLYTOCOMAANDDEATH !CUTEHEPATITISISCHARACTERISEDBYLIVERNECROSISFOLLOWEDBYANINFLAM MATORYREACTION$EPENDINGONTHESEVERITYOFTHEHEPATITIS THEREMAYBE APOPTOSIS FOCALNECROSIS ANDCONFLUENTORBRIDGINGNECROSIS4HEINFLAMMA TORYINFILTRATECONSISTSOFROUNDCELLSANDNEUTROPHILS)NFECTIONWITH#!6  IS USUALLY CHARACTERISED BY CONFLUENT AND BRIDGING NECROSIS IN THE CENTRI LOBULARZONEANDBYTHEPRESENCEOFINTRANUCLEARINCLUSIONSINHEPATOCYTES AND+UPFFERCELLS4HEVIRUSCANALSOBEDEMONSTRATEDHISTOLOGICALLYBYTHE INTRANUCLEARINCLUSIONBODIESORIMMUNOFLUORESCENCE

3YMPTOMS 3YMPTOMSCOMPRISEACUTEILLNESS APATHY SOMETIMESFEVER ANOREXIA VOMIT ING DEHYDRATION SOMETIMESICTERUSAND INSEVERECASES $)#)NFULMINANT HEPATITISTHEREISRAPIDWORSENINGWITHHEPATICENCEPHALOPATHY ICTERUSAND BLEEDING 4HE CLINICAL PICTURE IS ENTIRELY DEPENDENT ON THE SEVERITY AND EXTENTOFTHELIVERDAMAGE)NMOSTCASESACUTEHEPATITISISNOTASEVEREDIS EASE-OSTDOGSRECOVERCOMPLETELYWITHOUTTREATMENT

$IAGNOSIS )FTHEREISNOJAUNDICE THESYMPTOMSARENON SPECIFIC"LOODEXAMINATION REVEALS INCREASED LIVER ENZYMES ESPECIALLY!,4 SOMETIMES HYPERBILIRUBI NAEMIA5LTRASONOGRAPHICALLYTHELIVERISUSUALLYNOTABNORMALINSIZE ARCHI TECTUREORECHODENSITY/NLYINCASESOFVERYSEVEREORFULMINANTHEPATITIS THE LIVER MAY APPEAR TOO SMALL AND IRREGULAR4HE DIAGNOSIS IS ESTABLISHED BYLIVERBIOPSY)NDOGSBIOPSYNEEDLESOF'MAYBEUSEDTOOBTAINLARGE ENOUGH SAMPLES TO BE DIAGNOSTIC #OAGULATION SHOULD BE CHECKED FIRST IN CASEOF$)#ITISOFTENABNORMAL  $IAGNOSIS OF #!6  INFECTION MIGHT BE PERFORMED WITH PAIRED SERUM TITRETESTSANDCANBECONFIRMEDETIOLOGICALLYUSINGMOLECULARTESTS

4REATMENT 5SUALLY NO SPECIFIC TREATMENT IS NEEDED )N MORE SEVERE CASES SUPPORT IVE TREATMENT MAY EXTEND TO IV FLUID INFUSION TO CORRECT HYPOVOLEMIA



*AN2OTHUIZEN

SHOCK ACIDOSIS OR ALKALOSIS HYPOGLYCAEMIA AND ELECTROLYTE DISTURBANCES #ORTICOSTEROIDSARECONTRAINDICATEDBECAUSEOFTHESUSPICIONOFVIRALETIOLO GIES )N SEVERE LIVER DAMAGE AN ANTIBIOTIC AMOXYCILLIN MAY BE A HELPFUL SUPPORT TO ELIMINATE BACTERAEMIA DUE TO INADEQUATE HEPATIC CLEARANCE OF THE PORTAL CIRCULATION 0HALLOIDINE AND ACETAMINOPHEN INTOXICATION CAUSE OXIDATIVEDAMAGEANDMAYBETREATEDWITHSILYMARINMGKGDAY FORn DAYS!CETAMINOPHEN INTOXICATION MAY ALSO BE TREATED WITH THE COMBINA TIONOF. ACETYLCYSTEINEMGKG0/ EVERYHDURINGDAYS VITAMIN #nMGKG0/ EVERYHFORDAYS ANDCIMETIDINEMGKGBIDFOR  DAYS )F ACETAMINOPHEN TOXICITY HAS CAUSED HEMOLYSIS BLOOD TRANSFUSION MAYBEREQUIRED !CUTEHEPATITISRECOVERSSPONTANEOUSLYASARULE HOWEVER INABOUT OFTHECASESITPROGRESSESTOCHRONICHEPATITIS#HRONICDISEASEDOESNOTGIVE CLINICALSIGNSINTHEFIRSTMONTHSANDMAYBECOMECLINICALLYAPPARENTAFTERSEV ERALMONTHSWITHLIVERDYSFUNCTION)TISTHEREFORERECOMMENDEDTOPERFORM ACONTROLLIVERBIOPSY ORATLEASTTOMEASUREPLASMA!,4 nWEEKSAFTERTHE DIAGNOSISOFACUTEHEPATITISTODETECTCHRONICHEPATITISINANEARLYPHASE

,EPTOSPIROSIS %TIOLOGY ,EPTOSPIROSISISADISEASERESULTINGFROMINFECTIONWITH,EPTOSPIRACEAS4HE GENUS,EPTOSPIRAISDETERMINEDBYITSSEROVAR$UETOTHEIRPATHOGENICITY VIRULENCE DIFFERENT GROUPS OF SEROVARS HAVE BEEN SUBSUMED UNDER DIFFER ENT@NOMEN SPECIES $OGS ARE THE MAIN HOST FOR ONE THE MAJOR CAUSES OF LEPTOSPIROSIS THE,INTERROGANSSEROVAR,EPTOSPIRACANICOLA/THERSEROVARS LIKE , ICTEROHAEMORRHAGIAE AND , GRIPPOTYPHOSA ALSO CAUSE LEPTOSPIROSIS ,EPTOSPIRA ARE TRANSMITTED VIA DIRECT CONTACT OR URINE AND CONTAMINATED WATER FROM DOGS AND RODENTS LIKE RATS AND MICE RESPECTIVELY ; = )T IS NOTEWORTHYTHATLEPTOSPIROSISISANANTHROPOZOONOSIS ,EPTOSPIROSIS IS A FREQUENT CAUSE OF HEPATITIS IN DOGS ACCOUNTING FOR A SIGNIFICANTNUMBEROFACUTEHEPATITISCASESINDOGSWITHAPPROXIMATELY MORTALITY0ROPHYLACTICVACCINESAREAVAILABLE $OGSMAYBEASYMPTOMATICCARRIERSWHICHTRANSMITTHEINFECTIONWITHOUT BEINGILL%XPERIMENTALINFECTIONCAUSESDISEASEINYOUNGDOGS BUTOLDERDOGS MAYREMAINNON SYMPTOMATIC)NSPONTANEOUSCLINICALCASESILLNESSDEVELOPS AFTERANINCUBATIONOFnWEEKS;=4HESYMPTOMSAREDOMINATEDBYTHE URAEMIA )CTERUS IF PRESENT IS CAUSED BY INTRAHEPATIC CHOLESTASIS -YOSITIS MAYCAUSEPAINFULPALPATIONANDGAIT7ITHOUTTREATMENTRENALINSUFFICIENCY ISFATAL4HELIVERLESIONSARENOTSEVEREANDRECOVERSPONTANEOUSLY)NTHE LIVER THERE IS A NON SPECIFIC REACTIVE HEPATITIS "ACTERIAL ENZYMES CAUSE DETACHMENT OF THE TIGHT JUNCTIONS WHICH STIMULATE HEPATOCYTES INTO MITO SIS4HEREFOREANINCREASEDNUMBEROFMITOTICFIGURESINTHEHEPATOCYTESIS

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CHARACTERISTIC$UETOINTRAHEPATICCHOLESTASISNEARLYALLCASESAREDISTINCTLY JAUNDICED3YMPTOMSAREMAINLYDETERMINEDBYACUTERENALFAILURE

3YMPTOMS 4HESYMPTOMSCOMPRISEMALAISE OFTENFEVER VOMITING JAUNDICE SOMETIMES DIARRHOEA MUSCLEPAIN SOMETIMESPETECHIAEDUETOTHROMBOCYTOPENIAASA RESULTOF$)#

$IAGNOSIS 4HE DISEASE IS CHARACTERISED BY ACUTE ONSET AND ICTERUS (OWEVER SINCE SYMPTOMSMIGHTBEUNSPECIFIC DIAGNOSISISSUPPORTEDBYLABORATORYTESTING "LOODEXAMINATIONREVEALSURAEMIAANDCHOLESTASISWITHELEVATEDBILIRUBIN !0 GAMMA'4ANDBILEACIDS#0+ REFLECTINGMYOSITIS ISOFTENELEVATED AND MANYCASESHAVETHROMBOCYTOPENIA5RINEEXAMINATIONMAYREVEALTUBULAR EPITHELIALCELLSINTHESEDIMENT ANDORPROTEINURIA ,IVERHISTOLOGYUSUALLYSHOWSNON SPECIFICREACTIVEHEPATITIS WHICHMAY OCCURINANYTYPEOFSEPSIS4HEDIAGNOSISCANBEMADEBYSEROLOGY4HERAPID )G- PEAK IS MAXIMAL AFTER  DAYS FOLLOWED AT LEAST n DAYS LATER BY A LONG LASTING)G'PEAK)'-STAYSHIGHFORnWEEKS ANDSPECIFICMEASURE MENT OF )G- IN SERUM IS THE ONLY METHOD TO CONFIRM THE DIAGNOSIS IN AN EARLYSTAGE)G'MAYINDICATECHRONICINFECTIONORMAYBEDUETOVACCINA TION)NCREASING)G'OVERTIMEINDICATESACTIVEINFECTION 3INCE SEROLOGY IS NOT ALWAYS A RELIABLE METHOD ETIOLOGICAL DIAGNOSIS SHOULD BE CONFIRMED BY EITHER DETECTION OF THE AGENS IN LIVER BIOPSIES ,EVADITI OR 7ARTHIN 3TARRY STAINING OR BACTERIAL CULTURE IE /XOID 3ELECTIVE,EPTOSPIRA "ROTH $IAGNOSTIC0#2ISALSOAVAILABLE

4REATMENTANDPROPHYLAXIS 0ENICILLINISGIVENUNTILKIDNEYFUNCTIONHASRECOVEREDORSTABILISED ANDTHEN STREPTOMYCINISGIVENONTWOCONSECUTIVEDAYS!LTERNATIVELY CEPHALOSPORINS AREWELLEFFECTIVE;=4HISPREVENTSTHECONTINUINGEXCRETIONOF,EPTOSPIRA IN THE URINE4HE URINARY SHEDDING OF ,EPTOSPIRA STOPS TWO DAYS AFTER THE STARTOFPENICILLINADMINISTRATIONANDREMAINSABSENTASLONGASPENICILLINIS CONTINUED0REVENTIONBYVACCINATIONISIMPORTANTFORDOGSATRISKSUCHAS HUNTINGDOGSORDOGSWHICHLIKETOSWIM 4HE PROGNOSIS DEPENDS ON THE DEGREE OF KIDNEY FAILURE $ESPITE GOOD THERAPYTHEINFECTIONISUSUALLYFATAL!CUTEDISEASEWITHJAUNDICEANDURAE MIASHOULDIMMEDIATELYBETREATEDASIFITISLEPTOSPIROSIS UNTILTHEDIAGNOSIS ISDEFINITELYMADE



*AN2OTHUIZEN

#HRONICHEPATITISANDCIRRHOSIS #HRONIC HEPATITIS IN DOGS ;n= IS CHARACTERISED BY PERIPORTAL FIBRO SIS INFILTRATION OF LYMPHOCYTES AND PLASMA CELLS AND PERIPORTAL LIVER CELL APOPTOSIS OR NECROSIS4HE APOPTOTIC HEPATOCYTES SHRINK AND ARE ACIDIPHI LIC 0ARENCHYMAL EXPANSION OF THE INFLAMMATION AND FIBROSIS MAY CAUSE PORTO PORTAL OR PORTO CENTRAL BRIDGING SEPTA 0ORTO CENTRAL FIBROSIS CAUSES CIRRHOSIS ASTHEEND STAGEOFCHRONICHEPATITIS-ACRONODULARCIRRHOSISISTHE COMMONFORMINDOGS BUTMICRONODULARCIRRHOSISISESPECIALLYSEENINDIF FERENTFORMSOFCHRONICHEPATITISDUETOCOPPERSTORAGE!DVANCEDFIBROSIS EXTENDSTOCIRRHOSISINANEGATIVEVICIOUSCIRCLE REGARDLESSOFTHEUNDERLYING CAUSE#URATIVEINTERVENTIONISMORESUCCESSFULIFINITIATEDINEARLYSTAGESOF THEDISEASE4HEREFORE FASTANDACCURATEDIAGNOSISMAYBEPIVOTAL#HRONIC HEPATITISANDCIRRHOSISCAUSEINTRAHEPATICCHOLESTASIS BUTINONLYSOME OFTHECASESTHEREISICTERUS

%TIOLOGY #HRONIC ACTIVE HEPATITIS MAY BE THE RESULT OF A VIRAL INFECTION #ANINE !DENOVIRUS ISTHEONLYKNOWNCANINEHEPATITISVIRUS(OWEVER ITISLIKELY THAT THERE ARE MORE DIFFERENT YET UNKNOWN HEPATITIS VIRUSES IN DOGS ; n=!LTHOUGHINFECTIONWITH#!6 MIGHTBECOMECHRONICINVACCINATED ANIMALS #!6 INFECTIONRESULTSINFULMINANTHEPATITISINALLNON VACCINATED ANIMALS; =#!6 TITRESAREUSUALLYLOWINDOGSWITHCHRONICHEPATITIS 4HELYMPHOCYTICANDPLASMACELLULARINFLAMMATION ANDTHEGOODRESPONSE TO IMMUNOSUPPRESSIVE DRUGS INDICATE THAT A SELF PERPETUATING IMMUNE COMPONENTOFLIVERCELLDESTRUCTIONISINVOLVEDINTHECHRONICPROGRESSION #HRONICHEPATITISINDOGSMAYALSOBECAUSEDBYTOXINSSUCHASAFLATOXICOSIS )NHERITED COPPER ACCUMULATION ALSO LEADS TO DAMAGE OF HEPATOCYTES WITH SECONDARYHEPATITISANDFIBROSIS;n=SEEBELOW #OPPERACCUMULATION ANDINFLAMMATION HOWEVER BEGININZONESOFTHELIVERLOBULESANDNOTIN ZONEASINOTHERTYPES;=

0ATHOGENESIS 'RADUALLYPROGRESSIVELIVERCELLNECROSISMAYCAUSEACONTINUINGELEVATION OFALLLIVERENZYMESANDTHEBILEACIDS(OWEVER INNOTVERYACTIVEHEPATITIS ANDINENDSTAGESINWHICHCIRRHOSISHASDEVELOPED THERELEASEOFENZYMES INTOTHEPLASMAMAYBEINSIGNIFICANTANDTHENTHEENZYMESMAYBENORMAL OR SLIGHTLY ELEVATED )CTERUS DOES NOT ALWAYS DEVELOP #HRONIC HEPATITIS IS ALWAYSADIFFUSEPROCESSTHROUGHOUTTHELIVER,IVERFUNCTIONISDIMINISHED BY THE LOSS OF FUNCTIONAL TISSUE AND REDUCED PORTAL BLOOD FLOW4HERE ARE OFTEN LOW ALBUMIN AND FIBRINOGEN LEVELS (EPATIC ENCEPHALOPATHY MAY

(EPATITISINDOGS



DEVELOP IF PORTOSYSTEMIC COLLATERALS ARE FORMED 4HE END STAGE IS USUALLY CIRRHOSIS (YPOALBUMINAEMIA AND PORTAL HYPERTENSION MAY CAUSE ASCITES #HRONIC HEPATITIS MAY OCCUR AT ANY AGE )N THE BREEDS IN WHICH AN ABNOR MALCOPPERMETABOLISMCAUSESHEPATITIS THEGRADUALACCUMULATIONOFCOP PERUSUALLYLEADSTOCLINICALSIGNSATANAGEOFnYEARS#HRONICHEPATITIS OCCURSINALLBREEDS BUTTHEMOSTFREQUENTLYAFFECTEDBREEDSARE,ABRADOR 2ETRIEVERS'OLDEN2ETRIEVERSTOALESSEREXTENT $OBERMANN0INSCHERS ALL 3PANIELBREEDS "EDLINGTON4ERRIERS AND7EST(IGHLAND7HITE4ERRIERSSEE ALSOHEPATITISDUETOCOPPERSTORAGE 4HEINCIDENCEOFCHRONICHEPATITISIS RELATIVELY HIGH IT IS ONE OF THE MOST COMMON LIVER DISEASES IN COMPANION ANIMALSANDACCOUNTSFORABOUTOFTHECASESINAREFERRALCLINIC

3YMPTOMS 4HEMOSTFREQUENTSYMPTOMSAREAPATHY REDUCEDAPPETITE VOMITING POOR ENDURANCE POLYDIPSIA ANDINABOUTOFTHECASESICTERUS)NADVANCED CASES WITH DECOMPENSATION OF THE LIVER FUNCTIONS AND PORTAL HYPERTENSION THEREMAYBEASCITESANDHEPATICENCEPHALOPATHY3O CALLED@BLUEEYESTHAT AREARESULTOFSTRUCTURALCHANGESINTHESCLERACANFREQUENTLYBEOBSERVEDIN DOGSWITHCHRONIC#!6 INFECTION

$IAGNOSIS 0HYSICAL EXAMINATION USUALLY REVEALS NO SPECIFIC FINDINGS !LL OF THE LIVER ENZYMESAREMOREORLESSINCREASED BUT!,4ISTHEMOSTSENSITIVEPARAM ETER ALSOINEARLYSTAGES)NADVANCEDCASESTHEREMAYBEHYPOALBUMINAE MIA4HEDIAGNOSISCANONLYBEMADEBYLIVERBIOPSY5LTRASONOGRAPHYMAY REVEALASMALLLIVERWITHANIRREGULARSURFACEANDSTRUCTURE)NLESSADVANCED CASESTHEREARENOULTRASONOGRAPHICABNORMALITIES2EGARDINGTHEVERYHIGH FREQUENCYOFCOPPERSTORAGEDISEASESINDOGSITISADVISABLETOPERFORMHIS TOCHEMICALCOPPERSTAININGINALLCASESEG RUBEANICACIDSTAIN $IAGNOSIS OF#!6 INFECTIONCANONLYBECONFIRMEDUSINGLABTESTS

4REATMENT 4HERE IS NO SPECIFIC TREATMENT AVAILABLE TO DATE )MMUNOSUPPRESSION MAY SLOW THE IMMUNE COMPONENT OF THE PATHOGENESIS 0REDNISOLONE  MGKG DAY ISTHEUSUALDRUGGIVENFORATLEASTWEEKSANDINMOREACTIVEADVANCED STAGESFORnWEEKS)FTHESIDEEFFECTSOFSTEROIDSAREINTOLERABLEMG AZATHIOPRINEKG DAYMAYBEUSED)TISIMPORTANTTOEVALUATETHERESPONSE TO TREATMENT BY LIVER BIOPSIES -EDICATION IS AIMED TO ACHIEVE COMPLETE HISTOLOGICALREMISSIONOFTHEINFLAMMATORYPROCESSANDOFHEPATOCYTEAPOP



*AN2OTHUIZEN

TOSIS WHICHOCCURSUSUALLYAFTERnWEEKS7ITHOUTTREATMENT THEDISEASE PROGRESSESTOCIRRHOSIS )NCASESWITHCOPPERACCUMULATIONTHEMOSTEFFECTIVEDRUGISPENICILLA MINE GIVENINTWODOSESPERDAYMGKGDAY 4HEUSUALTREATMENTPERIOD ISWEEKS AFTERWHICHAFOLLOW UPHISTOLOGICALEVALUATIONSHOWSIFPENICIL LAMINEMAYBEDISCONTINUEDANDBEREPLACEDBYZINCGLUCONATETOPREVENT REACCUMULATIONOFCOPPER4HEREAREEFFECTIVEHEPATICSUPPORTCOMMERCIAL DIETSWHICHCONTAINLITTLECOPPERANDSEVERALANTIOXIDANTS !PARTFROMSPECIFICTREATMENTDIRECTEDATTHEHEPATITIS ADVANCEDSTAGE CASES NEED SUPPORTIVE CARE TO PREVENT OR TREAT DEHYDRATION ASCITES AND MANAGEMENTOF(%4HEPRESENCEOFPORTOSYSTEMICCOLLATERALCIRCULATIONAS APREREQUISITEFOR(%CANBEPREDICTEDWITHANAMMONIATOLERANCETEST 4HEPROGNOSISOFCHRONICHEPATITISISGUARDEDTHEDISEASECANBESTOPPED COMPLETELY IN MANY DOGS (OWEVER IN MANY CASES THERE ARE RECURRENCES WHICH FINALLY DETERMINE A GUARDED PROGNOSIS #OPPER STORAGE DISEASES MAY BE TREATED WITH COMPLETE SUCCESS AND HAVE A MUCH BETTER PROGNOSIS $EPENDINGONTHEPRESENCEOFCOLLATERALSDOGSMAYREQUIREPERMANENTSUP PORTWITHALIVERSUPPORTDIETANDLACTULOSE

#HRONICHEPATITISDUETOHEPATICCOPPERSTORAGE %TIOLOGY (EPATITISINCOPPERSTORAGEDISEASESOCCURSASARESULTOFANINHERITEDDEFECT OF HEPATIC COPPER METABOLISM &OOD CONTAINS AN EXCESS OF COPPER WHICH IS ABSORBED IN THE SMALL INTESTINES AND CLEARED FROM THE PORTAL BLOOD BY THELIVER4HEEXCESSISNORMALLYEXCRETEDINTOTHEBILEBYTHEHEPATOCYTES #OPPERISALSOANESSENTIALELEMENTANDITISDISTRIBUTEDTOTHEBODYBYTHE LIVERAFTERINCORPORATIONINCERULOPLASMIN4HENORMALMETABOLICPATHWAYS OFCOPPERINTHEHEPATOCYTESAREONLYINPARTKNOWNINTRACELLULARTRAFFICK ING IS ONLY IN PROTEIN BOUND FORM &REE COPPER CAUSES OXIDATIVE DAMAGE TOTHECELLS RESULTINGINLIVERCELLAPOPTOSISANDANINFLAMMATORYREACTION !CCUMULATIONOFCOPPERANDINFLAMMATIONOCCURAROUNDTHECENTRALVEINS INZONEOFTHELIVERLOBULES#HOLESTASISMAYALSOCAUSESOMECOPPERACCU MULATION WHICH IS ALWAYS LOCALISED IN THE PORTAL AREAS ZONE  AND ALSO ISMUCHLESSPRONOUNCEDTHANTHEZONEACCUMULATIONINPRIMARYCOPPER STORAGE DISEASES ;= #OPPER RELATED HEPATITIS IF UNTREATED PROGRESSES TO CHRONIC HEPATITIS AND CIRRHOSIS4HE GRADUAL ACCUMULATION LEADS TO CLINICAL DISEASETYPICALLYATANAGEOFnYEARSINMOSTDOGS(IGHHEPATICCOPPER CONCENTRATIONS MGGDRYTISSUEINDICATEANINHERITEDFORMOFCOPPER STORAGEDISEASENORMALDOGSHAVELEVELSMGG(ISTOCHEMICALSTAINING WITHRUBEANICACID SHOWSTHEZONALDISTRIBUTIONWHICHISANESSENTIALCLUE TOTHEDIAGNOSIS

(EPATITISINDOGS



4HIS DISEASE OCCURS IN DIFFERENT BREEDS ;n= "EDLINGTON 4ERRIERS ,ABRADOR 2ETRIEVERS $OBERMANN 0INSCHERS ALL 3PANIEL BREEDS 7EST (IGHLAND7HITE4ERRIERS $ALMATIAN DOGS !NATOLIAN 3HEPHERDS AND 3KYE 4ERRIERS /NLY IN "EDLINGTON 4ERRIERS WHICH HAVE AN AUTOSOMAL RECESSIVE DISEASE THE UNDERLYING GENE DEFECT A DELETION IN THE #/--$ GENE HAS BEEN FOUND6ERY RECENTLY RELIABLE $.! TESTS FOR THE DELETION IN THE #/--$GENEHAVEBEENREPORTED; =&ORNONEOFTHEOTHERBREEDS THECAUSATIVEGENEORA$.!MARKERISKNOWN BUTONGOINGRESEARCHINSEV ERALBREEDSWILLREVEALNEWGENEMUTATIONSWITHINAFEWYEARS )T HAS RECENTLY BEEN SHOWN ; = THAT $OBERMANN 0INSCHERS AND ,ABRADOR 2ETRIEVERS HAVE AN INHERITED FORM OF COPPER STORAGE DISEASE WHICH AFFECTS ABOUT  OF THESE POPULATIONS )N $OBERMANN 0INSCHERS THIS CHRONIC HEPATITIS IS VERY AGGRESSIVE AND NEARLY EXCLUSIVELY LINKED TO FEMALES#OPPER ASSOCIATEDHEPATITISOCCURSALSOINDIFFERENT3PANIELBREEDS AND$ALMATIANDOGS)NGENERAL WEHAVERECENTLYSHOWNNOTYETPUBLISHED THATOFALLDOGSWITHHEPATITISHAVEANUNDERLYINGDISORDEROFCOPPER METABOLISM

0ATHOGENESIS 4HE INCREASED COPPER CONCENTRATION DUE TO GRADUAL ACCUMULATION IS AFTER  YEAR OF AGE /XIDATIVE DAMAGE CAUSES LIVER CELL DEATH ACTIVATION OF THE +UPFFER CELLS AND AN INFLAMMATORY REACTION IN ZONE  #HRONIC PERSISTENT HEPATITISLEADSTOLOSSOFREGENERATIVECAPACITYANDFIBROSIS)NTHEENDSTAGE CIRRHOSISMAYDEVELOP)NCOPPERSTORAGEDISEASESTHISISALWAYSMICRONODU LAR CIRRHOSIS WHEREAS IN NON COPPER ASSOCIATED FORMS OF CHRONIC HEPATITIS THEREGENERATIVENODULESAREMACRONODULAR $OGSWITHCOPPERACCUMULATIONMAYDEVELOPANACUTEHAEMOLYTICANAE MIA PROBABLYDUETORELEASEOFHIGHLYACCUMULATEDCOPPERFROMNECROTISING HEPATOCYTES"ECAUSELIVERFUNCTIONSAREALREADYREDUCED SUCHDOGSALWAYS HAVEDISTINCTJAUNDICE (ETEROZYGOTE CARRIERS CANNOT BE DISTINGUISHED PHENOTYPICALLY FROM HEALTHYANIMALS)N$OBERMANNSTHEDISEASEAFFECTSONLYFEMALES TYPICALLY ATANAGEOFnYEARS)NALLOTHERFORMSOFHEPATITISTHEREISAFEMALEOVER REPRESENTATION USUALLYFEMALESREPRESENTnOFALLCASES

3YMPTOMS 4HESYMPTOMSAREIDENTICALTOTHOSESEENINNON COPPER ASSOCIATEDCHRONIC HEPATITIS



*AN2OTHUIZEN

$IAGNOSIS /N THE BASIS OF PHYSICAL AND BLOOD EXAMINATIONS IT IS NOT POSSIBLE TO DIF FERENTIATE THIS DISEASE FROM HEPATITISCIRRHOSIS OR HAEMOLYSIS DUE TO OTHER CAUSES %ARLY SUBCLINICAL CASES CAN BE DISCOVERED BY AN INCREASE OF !,4 IN BLOOD OTHER ENZYMES OR BILE ACIDS ARE MUCH LESS SENSITIVE AND BECOME ABNORMALONLYINADVANCEDCASES4HEDIAGNOSISHEPATITISISBASEDONHISTO LOGICALEXAMINATIONANDCOPPERSTAININGOFLIVERBIOPSIESTHECENTROLOBULAR COPPERACCUMULATIONISASSOCIATEDWITH+UPFFERCELLACTIVATIONANDINFLAM MATIONANDINADVANCEDSTAGESWITHFIBROSIS

4REATMENT #OPPERSTORAGEDISEASECANBETREATEDWITHACOPPERBINDINGCHELATINGDRUG ;= 0ENICILLAMINE IS WIDELY AVAILABLE AND IS GIVEN IN TWO DAILY DOSES  MINBEFOREEACHMEALINADAILYDOSEOFnMGKG5RINARYEXCRETIONOF THEPENICILLAMIN COPPERCOMPLEXREDUCESFREECOPPERFOLLOWEDBYTHECOP PERBOUNDMETAL4HERESPONSETOTREATMENTISEVALUATEDBYFOLLOWUPLIVER BIOPSIESANDISINMOSTCASESSEENAFTERMONTHS)FTHEHEPATITISISCURED RECURRENCESHOULDBEPREVENTEDBECAUSETHEUNDERLYINGGENEDEFECTCANNOT BETREATEDANDTHEDISEASEWILLREOCCURUPONDISCONTINUATIONOFTREATMENT ,ONG TERMPREVENTIONMAYBEACHIEVEDWITHZINCMGKGDAY INDIVIDED DOSESWITHEACHMEAL:INCINDUCESTHEINTESTINALMETALLOTHIONEINPRODUC TION WHICHBINDSCOPPERANDPREVENTSITSABSORPTION2ECENTLYCOMMERCIAL LOW COPPERLIVERSUPPORTDIETSHAVEBECOMEAVAILABLEWHICHAREVERYEFFEC TIVEINPREVENTINGTHEDISEASE

,OBULARDISSECTINGHEPATITIS %TIOLOGY 4HEETIOLOGYOFTHISDISEASEISUNKNOWN4HEAUTHORHASSEENTHISFORMOF HEPATITISINKENNELSWHEREONEDOGAFTERANOTHERGOTILL ATDIFFERENTAGES7E CONSIDEREDTHISSUGGESTIVEFORANUNKNOWNINFECTIOUSORIGIN

0ATHOGENESIS 4HIS IS A SEVERE DISEASE WITH PERICELLULAR FIBROSIS AROUND ALL HEPATOCYTES 4HE AMOUNT OF FIBROUS TISSUE IS EXCESSIVE CAUSING SEVERE PORTAL HYPERTEN SION ASCITES PORTOSYSTEMICACQUIREDCOLLATERALSANDHEPATICENCEPHALOPATHY 4HEPROGRESSIONISUSUALLYQUITEFASTCIRRHOSISISFORMEDWITHINnWEEKS TIME WHEREASFOROTHERFORMSOFCHRONICHEPATITISTHISISSEVERALMONTHSOR

(EPATITISINDOGS



YEARS7ITHSPECIFICSTAININGS#+ ANABUNDANTBUTAPPARENTLYINADEQUATE PROLIFERATIONOFHEPATICPROGENITORCELLSISSEENTHISDISEASESHOWSTHEMOST PROMINENTPROGENITORCELLACTIVATIONOFALLCANINELIVERDISEASESANDMAYBE ANEXCELLENTMODELTOSTUDYSIGNALSINVOLVEDINTHISPROCESS

3YMPTOMS 3YMPTOMS ARE WEIGHT LOSS VOMITING POLYURIA FOLLOWED BY ASCITES AND HEPATICENCEPHALOPATHY

$IAGNOSIS !BDOMINAL FLUID IS CLEAR COLOURLESS OR YELLOW IN CASE OF ICTERUS!T BLOOD EXAMINATION LIVER ENZYMES MAY OR MAY NOT BE INCREASED BUT BILE ACIDS ARE!MMONIAISOFTENINCREASEDANDTHEAMMONIATOLERANCETESTISUSUALLY ABNORMAL ,IVER BIOPSY REVEALS THE CHARACTERISTIC CHANGES ESPECIALLY WITH COLLAGENSTAINS

4REATMENT )NOUREXPERIENCEALLCASESDIEBECAUSEOFLIVERDECOMPENSATION

#OMPARATIVEASPECTSOFHEPATITISINDOGSANDMAN ,IVER DISEASES ARE A MAJOR FOCUS OF RESEARCH IN THE &ACULTY OF6ETERINARY -EDICINE0ROGRAM4ISSUE2EPAIR 4HEREARESEVERALASPECTSOFCANINEHEP ATITISWHICHMAKECOMPARISONWITHHUMANHEPATITISVERYUSEFUL!SAWHOLE LIVER DISEASES AND ESPECIALLY DIFFERENT FORMS OF HEPATITIS IN DOGS DEVELOP HIGHLY SIMILAR TO HUMAN HEPATITIS FULMINANT ACUTE CHRONIC  4HIS MAKES DOGDISEASESINTERESTINGTOSTUDYIMPORTANTASPECTSINTHEPATHOGENESISOF THE DISEASE7E HAVE SHOWN THAT IN HUMANS AND DOGS IDENTICAL PROCESSES WITHRESPECTTOFORMATIONOFFIBROSIS REGENERATION STEMCELLACTIVATION AND OXIDATIVEDAMAGEOCCUR;n=)NMOSTASPECTSIDENTICALPATHOGENESISAND PATHOPHYSIOLOGY OF CANINE AND HUMAN HEPATITIS MAKE THESE SPONTANEOUS DOGDISEASESIDEALMODELSTOSTUDYTHEEFFECTOFNEWMODESOFINTERVENTION TO STIMULATE REGENERATION AND REDUCE OR PREVENT CIRRHOSIS /NE UPCOMING ASPECTOFINTERESTTOUNDERSTANDNEWPOSSIBILITIESFORTREATMENTOFPRESENTLY UNTREATABLE STAGES OF HEPATITIS IS THE LIVER STEM CELL 0RECISE UNDERSTAND INGOFTHESTEMCELLNICHEOFTHELIVERISESSENTIALINORDERTODEVELOPNEW THERAPIESAIMEDATSTIMULATINGTHEPROLIFERATIONANDDIFFERENTIATIONOFTHESE PROGENITORCELLS7EHAVESHOWNUNPUBLISHEDRESULTS THATSTEMCELLACTIVA



*AN2OTHUIZEN

TION IN DOGS AND MAN OCCURS IN A HIGHLY COMPARABLE WAY IN THE DEVELOP MENTOFHEPATITIS;=)TISALSOPOSSIBLETODRAWBENEFICIALCONCLUSIONSFROM DISTINCTLY DIFFERENT FORMS OF HEPATITIS SUCH AS LOBULAR DISSECTING HEPATITIS ,$( WHICHISMOSTCOMPARABLEWITHNEONATALHEPATITISINHUMANS4HE LIVERSOFDOGSWITH,$(ARELOADEDWITHACTIVATEDPROGENITORCELLS WHICHIN THEFACEOFEXCESSIVEFIBROSISISFUNCTIONALLYINEFFECTIVE4HISDISEASEOFFERS CHANCESTOSTUDYSTEMCELLACTIVATIONANDTHERELATIONSWITHFIBROSISANDSTEL LATECELLACTIVATIONUSINGTECHNIQUESSUCHASMICRODISSECTION MICROARRAY AND IMMUNOHISTOCHEMISTRY 4HE VERY FREQUENT OCCURRENCE OF COPPER STORAGE DISEASES AS A CAUSE OF HEPATITISINDOGSISASPECIFICFEATUREOFCANINEHEPATITIS0UREBREDDOGBREEDS HAVEBEENFORMEDOVERTHEPASTnYEARSBYCONTINUOUSSELECTIONOF DESIRED CHARACTERISTICS REGARDING BEHAVIOUR AND EXTERIOR 4HIS STRINGENT SELECTION AND INBREEDING HAS CAUSED ACCUMULATION OF ORIGINALLY SPORADIC DISEASE GENES IN ALL BREEDS SO THAT NOWADAYS EACH DOG BREED HAS SEVERAL HIGHLYFREQUENTBREED SPECIFICDISEASES)NTHISWAYDEFECTSINTHEFUNCTIONOF GENESINVOLVEDINCOPPERMETABOLISMHAVEALSOBYCHANCEBEENSEGREGATED OVER DOG BREEDS 4HIS HAS CAUSED THE PRESENCE OF MANY DIFFERENT COPPER METABOLISMDISEASESINDIFFERENTDOGBREEDS!LSODUETOTHEFACTTHATTRADI TIONALLYDOGFOODSCONTAINAQUITEHIGHCOPPERCONCENTRATION THEDIFFERENT DOGBREEDSPRESENTANEXCELLENTOPPORTUNITYTODETECTYETUNRESOLVEDPARTS OFTHECELLULARPATHWAYSOFCOPPERHANDLING)NTHEDOGBREEDSMENTIONED BEFORE AS AFFECTED BY COPPER STORAGE LIVER DISEASE WE HAVE EXCLUDED ALL PRESENTLYKNOWNCANDIDATEGENESINVOLVEDINCOPPERMETABOLISM4HEREFORE BY DEFINITION THESE DOGS WILL ELUCIDATE NEW ELEMENTS OF COPPER PATHWAYS 4HEHIGHLEVELOFINBREEDINGOFPUREBREDDOGSHASSIMPLIFIEDCOMPLEXDIS EASESTOSEEMINGLYMONOGENEOUSDISEASESSOTHATCOMPLEXCOPPERDISORDERS OFWHICHTHEGENETICBACKGROUNDWOULDNOTBECOMEAPPARENTORRESOLVABLE INHUMANSMAYBEUNRAVELLEDRELATIVELYEASILYINDOGS

2EFERENCES 



  

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#OMPARATIVE(EPATITIS EDBY/LAF7EBERAND5LRIKE0ROTZER ¥"IRKHËUSER6ERLAG"ASEL3WITZERLAND



(EPATITISINHORSES !NDY%$URHAM 4HE,IPHOOK%QUINE(OSPITAL &OREST-ERE ,IPHOOK (AMPSHIRE '5*' 5NITED+INGDOM

!BSTRACT 4HE MAIN CAUSES OF HEPATITIS IN HORSES INCLUDE SERUM HEPATITIS CHOLANGIOHEPATITIS AND CHRONICACTIVEHEPATITISWITHOCCASIONALCASESOFHAEMATOGENOUSBACTERIALHEPATITISEG 4YZZERS DISEASE IN FOALS ABSCESSES VIRAL HEPATITIS PARASITISM AND CHRONIC INFILTRATIVE INFLAMMATORYDISEASE.OTALLCASESOFHEPATITISWILLBECLINICALLYAPPARENTDUETOTHELARGE RESERVECAPACITYOFTHELIVER(OWEVER SIGNSOFMARKEDHEPATICINSUFFICIENCYANDHEPATIC ENCEPHALOPATHY REDUCE THE LIKELIHOOD OF A SUCCESSFUL OUTCOME 3ERUM ENZYMES INCLUD ING ALKALINE PHOSPHATASE ASPARTATE AMINOTRANSFERASE GAMMA GLUTAMYLTRANFERASE AND GLUTAMATE DEHYDROGENASE OFFER AN APPROXIMATE REFLECTION OF HEPATIC DAMAGE WHEREAS FUNCTIONALINDICATORSSUCHASBILEACIDS BILIRUBIN ALBUMIN GLOBULINS UREAANDAMMONIA MAYPROVIDEMOREPROGNOSTICALLYUSEFULINFORMATION.EVERTHELESSALLSERUMBIOCHEMICAL PARAMETERSHAVESIGNIFICANTLIMITATIONSINTERMSOFSENSITIVITYORSPECIFICITY,IVERBIOPSY WHENGUIDEDBYULTRASONOGRAPHICIMAGES OFFERSTHEOPTIMALSAFEANDEFFECTIVEMEANSOF INVESTIGATINGSUSPECTEDHEPATITISINHORSESANDWILLPROVIDEUSEFULDIAGNOSTICANDPROG NOSTICINFORMATIONINADDITIONTOAIDINGSELECTIONOFTHERAPEUTICCHOICE 'ENERAL AND SUPPORTIVE CARE FOR EQUINE HEPATITIS CASES INCLUDES FLUID THERAPY ANTI PYRETICS AND DIETARY MANAGEMENT COMPRISING SMALL FREQUENT FEEDS OF LOW FAT GOOD QUALITY PROTEIN AND CEREAL BASED FEEDS SUCH AS GRASS GOOD GRASS HAY DRIED PROPRIETARY CHAFFS ALFALFA PROCESSEDWHEATMAIZEAND"VITAMINSUPPLEMENTS#ARESHOULDBETAKEN TO ENSURE THAT SUPPLEMENTS DO NOT CONTAIN POTENTIAL HEPATOTOXINS EG IRON  3PECIFIC THERAPYISUSUALLYSELECTEDONTHEBASISOFBIOPSYFINDINGSANDMAYCOMPRISEANTIBACTERI ALS ANTHELMINTICS GLUCOCORTICOIDSANDLACTULOSE

!ETIOLOGIES 4HEREARESIGNIFICANTGEOGRAPHICVARIATIONSINTHEPREVALENCEOFHEPATITISIN HORSES0UBLISHEDREVIEWSOFEQUINEHEPATICDISEASESUGGESTTHATHEPATITISIS RELATIVELYCOMMONINTHE53!LARGELYASARESULTOFSO CALLED@SERUMHEPA TITIS;n=/THERCOMMONCAUSESOFEQUINEHEPATITISCOMPRISECHOLANGIO HEPATITISANDCHRONICACTIVEHEPATITISBOTHOFWHICHHAVESIMILARPREVALENCE IN53!AND5+4AB 3EVERALSPECIFICTYPESANDCAUSESOFHEPATITISIN



!NDY%$URHAM

4ABLE  2ELATIVE PREVALENCE OF EQUINE HEPATITIDES DERIVED FROM FOUR LARGE SURVEYS OF LIVER DISEASECASES $ISEASETYPE

53!STUDIESN ; =

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OFTOTALHEPATOPATHYCASES OFTOTALHEPATOPATHYCASES 3ERUMHEPATITIS





#HOLANGIOHEPATITIS





#HRONICACTIVEHEPATITIS













!BSCESS 4OTALHEPATITISCASES

HORSES ARE DISCUSSED BELOW AND ARE ASSOCIATED WITH SPECIFIC CLINICAL CLINI COPATHOLOGICAL GROSSPATHOLOGICALORHISTOPATHOLOGICALDIAGNOSTICFEATURES (OWEVER INTHEAUTHORSEXPERIENCESUCHCLEARDIAGNOSTICCATEGORISATIONIS IMPOSSIBLEINMANYCLINICALCASESSEENINPRACTICE4HISVIEWISSUPPORTEDBY THEMOREGENERALCATEGORISATIONAPPEARINGINPUBLISHEDREVIEWSOFEQUINE LIVERDISEASECASES;n= #ASES OF ACUTE HEPATITIS AND NECROSIS IN ADULT HORSES KNOWN AS SERUM HEPATITISOR4HEILERSDISEASE ARESEENFREQUENTLYINSOMEGEOGRAPHICLOCA TIONSSUCHASTHE53!; =0ROGNOSISISGUARDEDTOPOORWITHTHEMAJORITY OFAFFECTEDHORSESSUCCUMBING;=!SIMILARDISEASEHASALSOBEENREPORTED FROM&RANCE;=AND4URKEY;=4HECONDITIONISRAREINTHE5+ALTHOUGH SEVERALCASESHAVEBEENSEENBYTHISAUTHOREITHERASISOLATEDCASESOROUT BREAKS !LTHOUGH MOST CASES HAVE NO OBVIOUS TRIGGER FACTORS SOME MAY FOLLOWBETWEENnWEEKSAFTERTETANUSANTITOXINADMINISTRATIONANDHAVE ALSOBEENREPORTEDFOLLOWINGUSEOFOTHEREQUINEBIOLOGICALSSUCHASPLASMA ; = $ESPITE THE SIMILARITIES WITH HUMAN HEPATITIS " VIRUS INFECTION ;= ANDTHELONGHELDSUSPICIONOFAHAEMATOGENOUSINFECTIONCAUSINGTHIS CONDITION NOINFECTIOUSAGENTHASYETBEENIDENTIFIED; =)NSECTVECTORS HAVEBEENSUGGESTEDASANEXPLANATIONOFTHESUMMERANDAUTUMNPEAKSOF DISEASE;= !LTHOUGHNOTREPORTEDASASPECIFICENTITY THECOMMONESTFORMOFHEPA TITISINHORSESSEENBYTHISAUTHORISASSOCIATEDWITHLYMPHOCYTICPORTALINFIL TRATESWITHOUTOTHERHEPATOPATHICFINDINGSSUCHASNECROSIS BILIARYHYPERPLA SIAANDFIBROSIS3UCHCASESARESEENSPORADICALLYORASOUTBREAKSANDHAVE EPIDEMIOLOGICANDHISTOPATHOLOGICRESEMBLANCEOFVIRALHEPATITIDESINOTHER SPECIESALTHOUGHSEROLOGICEXAMINATIONSAREUSUALLYUNPRODUCTIVE#AUTION SHOULDBEEXERCISEDHOWEVERWHENMAKINGADIAGNOSISOFHEPATITISONTHE BASISOFMILDPORTALLYMPHOCYTICINFILTRATESASONESTUDYFOUNDSUCHCHANGES TO BE PRESENT IN  OF   LIVER SPECIMENS FROM NORMAL HORSES ;= 6IRALHEPATITIDESARENOTWELLRECOGNISEDINHORSESALTHOUGHEQUINEHERPES VIRUSINFECTIONMAYRESULTINSEVEREHEPATICNECROSISINNEONATES;=AND SOMETIMESHEPATITISINOLDERHORSES; =(EPATICMONONUCLEARPHAGO

(EPATITISINHORSES



CYTES+UPFFERCELLS AREANIMPORTANTSITEOFVIRALREPLICATIONANDLATENCYIN EQUINEINFECTIOUSANAEMIAVIRUSINFECTIONANDLYMPHOIDHEPATITISISCHARAC TERISTICOFACTIVEINFECTION; =)NARECENTSTUDYOF%GYPTIANHORSES WEREFOUNDTOBESEROPOSITIVEFORHUMANHEPATITIS%VIRUSALTHOUGHTHERE WASNOSPECIFICEVIDENCEOFLIVERDISEASEINTHESECASES;= "ACTERIAL HEPATITIS MAY ARISE HAEMATOGENOUSLY AND IS WELL RECOGNISED IN ASSOCIATION WITH NEONATAL SEPTICAEMIA CAUSED BY SEVERAL BACTERIAL SPE CIES ;= ,ESS COMMONLY HAEMATOGENOUS BACTERIAL HEPATITIS HAS BEEN REPORTEDASPARTOFAMULTISYSTEMICINFECTIONWITHSPECIFICPATHOGENSSUCH AS 2HODOCOCCUS EQUI !CINETOBACTER CALCOACETICUS %HRLICHIA RISTICII AND 9ERSINIAENTEROCOLITICA;n=#LOSTRIDIALHEPATITISISBESTRECOGNISEDASSPO RADICCASESOROUTBREAKSOF@4YZZERSDISEASEINFOALSBETWEENnWEEKSOF AGE;=4HISACUTEBACTERIALHEPATITISANDNECROSISISCAUSEDBY#LOSTRIDIUM PILIFORME AND A FAECAL ORAL ROUTE OF SPREAD IS SUSPECTED4HE CONDITION IS FREQUENTLY RAPIDLY FATAL BUT TREATMENT CAN BE SUCCESSFUL ;= ! SIMILARLY SEVEREACUTECLOSTRIDIALHEPATITISHASALSOBEENREPORTEDINADULTHORSESIN ASSOCIATIONWITH#NOYVIAND#HAEMOLYTICUM;n=,IVERABSCESSESARE REPORTEDRARELYINHORSESBUTMAYBECAUSEDBYAWIDEVARIETYOFBACTERIAL SPECIESINCLUDING"ACTEROIDESFRAGILIS #ORYNEBACTERIUMPSEUDOTUBERCULOSIS % COLI 3TAPHYLOCOCCUS AUREUS 3TREPTOCOCCUS EQUI SUBSP EQUI AND SUBSP ZOOEPIDEMICUS; n= 3EPTICBACTERIALCHOLANGIOHEPATITISINADULTHORSESANDFOALSISSUSPECTED TORESULTFROMREFLUXOFDUODENALCONTENTSALONGTHEHEPATICDUCTANDISUSU ALLY ASSOCIATED WITH 'RAM NEGATIVE ENTERIC BACTERIA SUCH AS !CTINOBACILLUS EQUULI "ACTEROIDES VULGATUS #ITROBACTER SP %SCHERICHIA COLI +LEBSIELLA PNEUMONIAE AND 3ALMONELLA SP ALTHOUGH 'RAM POSITIVE ISOLATES SUCH AS 3TREPTOCOCCUSSPAREALSOREPORTED; n=3EPTICCHOLANGIOHEPATITISHAS ALSO BEEN REPORTED IN ASSOCIATION WITH HEPATIC NEOPLASIA AND TREMATODE INFESTATION; ="ILIARYINFECTIONMAYPROVIDEFAVOURABLECONDITIONSCOM PRISING NIDUS FORMATION AND BILIARY STASIS THAT PREDISPOSES TO CHOLELITHIASIS /CCASIONALREPORTSOFVEGETABLEMATTERFOUNDWITHINCHOLELITHSALSOSUPPORT THISSEQUENCEOFEVENTS;=#HOLELITHIASISCASESAPPEARTOHAVEGEOGRAPHIC PREDISPOSITIONWITHMORECASESREPORTEDFROMTHE53!THANOTHERCOUNTRIES !S MOST EQUINE CHOLELITHS ARE COMPOSED OF CALCIUM SALTS BILIRUBINATE AND PHOSPHATE ;=THEPRACTICEOFALFALFAFEEDINGMAYHAVERELEVANCETOTHEIR AETIOLOGY3TONESASLARGEASCMDIAMETERAREREPORTEDANDPROGNOSISFOR RECOVERYWITHMEDICALORSURGICALMANAGEMENTISPOOR;= /THER ORGANISMS OCCASIONALLY REPORTED IN ASSOCIATION WITH HEPATITIS IN HORSES INCLUDE THE PROTIST 0YTHIUM INSIDIOSUM ;= PROTOZOANS INCLUDING #YCLOPOSTHIUMSP 0OLYMORPHELLAAMPULLAAND3ARCOCYSTISSP; =AND HELMINTHS SUCH AS %CHINOCOCCUS GRANULOSUS HYDATID CYSTS ;= &ASCIOLA HEPATICA ;n= &ASCIOLOIDES MAGNA ;= AND 3CHISTOSOMA SP ;= /THER LARVALNEMATODESINCLUDING0ARASCARISEQUORUM 3TRONGYLUSEDENTATUSAND3 EQUINUSMAYCAUSEHEPATITISDURINGTRANSITTHROUGHTHELIVERASPARTOFTHEIR NORMALMIGRATORYANDDEVELOPMENTALLIFECYCLE;n=



!NDY%$URHAM

#HRONICACTIVEHEPATITISISAPOORLYUNDERSTOODCONDITIONCHARACTERISEDBY PERSISTENTANDPROGRESSIVEPERIPORTALINFLAMMATORYINFILTRATES FIBROPLASIAAND BILIARYHYPERPLASIAANDISOCCASIONALLYSEENINADULTHORSES; =4HEAETIOL OGYOFSUCHCASESISSPECULATIVE3OMECASESAPPEARTODEVELOPFROMUNTREAT EDORNON RESPONSIVECASESOFSEPTICCHOLANGIOHEPATITISOR4HEILERSDISEASE ;=WHEREASOTHERSAPPEARTOBECONSISTENTLYLYMPHOCYTICWITHOUTEVIDENCE OFPRIORSEPSISORNECROSIS#HRONICHEPATOTOXICITY VIRALINFECTIONANDIMMUNE MEDIATEDDISEASEHAVEBEENPROPOSEDTOEXPLAINSOMECASES; = #HRONIC HEPATITIS HAS BEEN REPORTED IN SEVERAL HORSES AS PART OF A MULTISYSTEMIC INFILTRATIVE INFLAMMATORY DISEASE PROCESS OFTEN ADDITIONALLY INVOLVING SKIN LUNG INTESTINE AND OTHER ORGANS -ULTIFOCAL GRANULOMATOUS INFLAMMATIONWITHORWITHOUTEVIDENCEOF-YCOBACTERIA;n=AND MUL TISYSTEMIC EOSINOPHILIC EPITHELIOTROPHIC DISEASE -%%$ ; n= ARE THECOMMONESTFORMSOFCHRONICMULTIFOCALINFLAMMATORYDISEASEINHORSES #ASESUSUALLYPRESENTWITHSIGNSOFWEIGHTLOSSPOSSIBLYINASSOCIATIONWITH SKINLESIONS(EPATITISISMOREOFTENDISCOVEREDFOLLOWINGSERUMBIOCHEMI CALANALYSISTHANONTHEBASISOFCLINICALSIGNS

$IAGNOSIS 4HEREARETHREEFUNDAMENTALAIMSOFTHEINVESTIGATIONOFCASESOFSUSPECTED LIVERDISEASEFIRSTLY TODIFFERENTIATESUBJECTSGENUINELYSUFFERINGFROMLIVER DISEASEFROMTHOSEWHICHARENOTSECONDLY TODETERMINETHETYPEOFLIVER DISEASEAFFECTINGTHESUBJECTANDTHEREFOREAPPROPRIATETHERAPYANDTHIRDLY TODIFFERENTIATETHOSESUBJECTSWHICHARELIKELYTOSURVIVEFROMTHOSEWHICH ARENOT

#LINICALSIGNS 3IGNS OFTEN ASSOCIATED WITH HEPATITIS CASES IN HORSES INCLUDE DEPRESSION WEIGHT LOSS COLIC PYREXIA ANOREXIA PHOTOSENSITISATION NEUROLOGICAL SIGNS SEE BELOW DIARRHOEA JAUNDICE OEDEMA PRURITUS EPISTAXIS POLYDIPSIA POLYURIA DIFFUSE SKIN DISEASE AND CORONITIS ;   =4HE PRESENCE OF SEVERECLINICALSIGNSOFHEPATICINSUFFICIENCYHASMAJORPROGNOSTICRELEVANCE ;=(OWEVER HEPATICDISEASEISMORECOMMONTHANHEPATICINSUFFICIENCY ANDMANYCASESOFLIVERDISEASEINHORSESARESUBCLINICAL; n=)NONE STUDYOFSUSPECTEDEQUINEHEPATOPATHYCASES WERECONFIRMEDBYBIOPSY TOHAVESIGNIFICANTLIVERDISEASEBUTONLYOFTHESE WERESHOWING SPECIFICCLINICALSIGNSOFSUCH;=4HEREFOREABSENCEOFSPECIFICCLINICALSIGNS INASUBJECTSUSPECTEDTOBEAFFECTEDBYHEPATITISEG ONTHEBASISOFLABORA TORYRESULTS ISOFLIMITEDREASSURANCE (EPATITIDES HOWEVER WITH ASSOCIATED SYSTEMIC INFLAMMATORY RESPONSE MAY BE MORE LIKELY TO BE CLINICALLY PERCEPTIBLE PRIOR TO ONSET OF HEPATIC

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INSUFFICIENCY THAN NON INFLAMMATORY HEPATOPATHIES 3OME SPECIFIC CAUSES OFHEPATITISHAVEASUGGESTIVECLINICALPRESENTATION3ERUMHEPATITISCAUSES ACUTEHEPATICINSUFFICIENCYANDHASANACUTEPRESENTATIONOFMARKEDDEPRES SIONOFTENWITHNEUROLOGICSIGNS;=#HOLANGIOHEPATITISCASESWITHCHOLELITH FORMATION ARE ALSO READILY DIAGNOSED CLINICALLY WITH THE TYPICAL SIGNS OF COLIC PYREXIA AND JAUNDICE ; = -ULTISYSTEMIC INFLAMMATORY DISEASES AREUSUALLYSUSPECTEDASARESULTOFTHEIRINTESTINALORSKINSIGNSRATHERTHAN FROMHEPATITISALTHOUGHLABORATORYEVIDENCEOFLIVERDISEASEINAHORSEWITH PROTEINLOSINGENTEROPATHYANDCHRONICDERMATITISISSTRONGLYSUGGESTIVEOF THISCONDITION;= 4HE SYNDROME OF HEPATIC ENCEPHALOPATHY (% ENCOMPASSES A WIDE VARIETYOFNEUROLOGICSIGNSIDENTIFIEDINSUBJECTSWITHHEPATICINSUFFICIENCY AND PORTAL SYSTEMIC BYPASS ;= 3IGNS OF (% ARE USUALLY SUDDEN IN ONSET WHETHERTHEUNDERLYINGHEPATICDISEASEISACUTEORCHRONIC$IFFUSECEREBRAL ANDBRAINSTEMDYSFUNCTIONISMOSTCOMMONLYRECOGNISEDWITHDEPRESSION DISORIENTATION CIRCLING COMPULSIVEWALKING HEADPRESSING DYSPNOEALARYN GEALANDPHARYNGEALPARESIS BLINDNESS YAWNINGANDCOMABEINGOBSERVED MOSTFREQUENTLY/CCASIONALLYEXCITATIONINCLUDINGAGGRESSIONANDSEIZURES ARESEENBUTTHESESIGNSAREFARLESSFREQUENTTHANSIGNSOFDEPRESSEDNEU ROLOGIC FUNCTION /THER RARER SIGNS ATTRIBUTED TO (% INCLUDE PRURITUS FOOT STAMPING DYSPHAGIAANDGASTRICIMPACTION;    =

(AEMATOLOGY 2EPORTS OF HORSES WITH LIVER DISEASE HAVE FOUND HIGHLY VARIABLE AND NON SPECIFICHAEMATOLOGICALFINDINGSWITHNEUTROPHILIAANDLYMPHOPAENIABEING FAIRLY COMMON AND BOTH ANAEMIA AND ERYTHROCYTOSIS ALSO REPORTED ;   n=.EUTROPHILIAISACOMMONFINDINGINBACTERIALHEPATITISCASESAS PARTOFTHESYSTEMICINFLAMMATORYRESPONSEALTHOUGHONESTUDYFOUNDLEU COCYTOSIS AND NEUTROPHILIA TO BE ASSOCIATED WITH SEVERE NON INFLAMMATORY HEPATOPATHIESALSO;=%RYTHROCYTOSISWASALSORELATIVELYCOMMONINTHOSE CASES WITH A WORSE CLINICAL STATUS PROBABLY SECONDARY TO DEHYDRATION ;= !BSOLUTEERYTHROCYTOSISISRECOGNISEDASAPARANEOPLASTICSYNDROMEINCASES OFHEPATOBLASTOMAANDHEPATOCELLULARCARCINOMAINHORSES;n=ALTHOUGH THISHASNOTBEENREPORTEDINHEPATITISCASES

3ERUMBIOCHEMISTRY "IOCHEMICALSUBSTANCESMEASUREDINTHEBLOODOFSUSPECTEDEQUINE HEPA TITISCASESCANBESUBDIVIDEDINTOINTRACELLULARENZYMESREFLECTINGDAMAGED LIVERCELLSANDSUBSTANCESREFLECTINGIMPAIREDLIVERFUNCTION!LTHOUGHVERY USEFUL DIAGNOSTIC AND PROGNOSTIC INFORMATION IS OBTAINED FROM LABORATORY ANALYSISOFBLOODSAMPLES NOBIOCHEMICALTESTSAREABSOLUTELYACCURATEAND



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THECLINICIANWILLSOMETIMESBEMISLEDIFABSOLUTERELIANCEISPLACEDONSUCH INFORMATION;=.EVERTHELESSINCREASEDSERUMENZYMECONCENTRATIONSARE AREASONABLYRELIABLEINDICATOROFHEPATICDISEASEESPECIALLYWHENCORROBO RATEDBYINCREASESINSEVERALDIFFERENTENZYMES&URTHERMOREABNORMALLIVER FUNCTIONTESTSSUGGESTHEPATICINSUFFICIENCYINASUBJECTWITHINCREASEDSERUM ENZYMECONCENTRATIONS; =

3ERUMENZYMES 3EVERALINTRACELLULARENZYMESFOUNDINHEPATOCYTESANDBILIARYEPITHELIACAN BE USED TO INFER LIVER DISEASE INCLUDING ALANINE AMINOTRANSFERASE !,4 ALKALINE PHOSPHATASE !0 ARGINASE ASPARTATE AMINOTRANSFERASE !34 GAMMA GLUTAMYLTRANFERASE a'4 GLUTAMATE DEHYDROGENASE ',$( IDITOLDEHYDROGENASEANDLACTATEDEHYDROGENASE; n=WITH!0 !34 a'4AND',$(BEINGINTHEMOSTCOMMONUSAGE !0 HAS BEEN FOUND TO BECOME ELEVATED WITHIN  H OF ACUTE HEPATIC INSULTALTHOUGHSIGNIFICANTELEVATIONSHAVENOTBEENCONSISTENTLYREPORTEDIN ACUTE; =ORCHRONIC;n=HEPATOPATHIES)NCREASEDSERUMCONCENTRA TIONS OF!0 MAY ALSO BE DERIVED FROM INTESTINE INFLAMMATORY CELLS BONE ANDPLACENTA;=!0HASBEENSHOWNHOWEVER TOBESUPERIORTOMOSTOTHER ENZYMESFORPREDICTIONOFPROGNOSISINCASESOFLIVERDISEASE; = !LTHOUGH OFTEN CONSIDERED TO REFLECT CHRONIC HEPATOPATHIES ;   = a'4HASBEENSHOWNTOBEASENSITIVEINDICATOROFACUTEHEPATICINSULT ALSO ; = a'4 AND!34 ARE PROBABLY THE MOST SENSITIVE INDICATORS OF HEPATITISBUT LACKSPECIFICITY;=)NCONTRASTTOAGENERALLYHIGHREGARDFOR a'4ASTHEMOSTCLINICALLYUSEFULLIVER DERIVEDENZYMEINCOMMONUSAGE; = CASESAREFREQUENTLYSEENWITHINCREASEDa'4INWHICHLIVERBIOPSYFAILS TO IDENTIFY SIGNIFICANT LIVER DISEASE ;= #ONVERSELY CASES OF HEPATOPATHY WITHNORMALSERUMa'4CONCENTRATIONSARELESSCOMMONLYREPORTED;n= a'4WASFOUNDTOBEPROGNOSTICALLYUSEFULONLYINSUBJECTSWITHMARKEDLY INCREASEDLEVELSIUL ; =4HEPANCREASANDRENALTUBULESAREALSO RICH SOURCES OF a'4 ALTHOUGH RENALLY DERIVED a'4 IS WIDELY ACCEPTED TO APPEARINURINEANDNOTSERUM;= )THASBEENSUGGESTEDTHATRELATIVEDIFFERENCESINSERUMCONCENTRATIONS OFLIVERDERIVEDENZYMESMAYINFERTHEUNDERLYINGNATUREOFTHELIVERDISEASE ; =%XPERIMENTALSTUDIESHAVESUGGESTEDAPRIMARILYBILIARYSOURCEFOR a'4 HEPATOCELLULARSOURCESFOR!,4 !34 ',$(AND)$(ANDBOTHBILI ARYANDHEPATOCELLULARSOURCESFOR!0;n=!LTHOUGHTHEASSOCIATIONOF ENZYMEPATTERNSWITHSUBTYPESOFHEPATITISMAYBEANIMPERFECTGENERALISA TION HEPATOCELLULARDISEASESSUCHASSERUMHEPATITISWILLUSUALLYBEASSOCIAT EDWITHSIMILARLYMARKEDINCREASESINALLENZYMESALTHOUGHCHOLANGIOHEPATI TISCASES ESPECIALLYWITHBILIARYOBSTRUCTION WILLSHOWTHEGREATESTINCREASES IN a'4 AND !0 ; = (OWEVER ELEVATIONS IN SERUM a'4 HAVE BEEN REPORTEDINASSOCIATIONWITHACUTEHEPATOCELLULARNECROSISINTHEABSENCEOF

(EPATITISINHORSES



NOTABLE BILIARY INSULT AND OCCASIONAL CASES OF LIVER DISEASE ARE SEEN WHERE INCREASINGCONCENTRATIONSOFSERUMa'4MAYBENOTEDDESPITEEVIDENCEOF IMPROVEMENTOFTHEHEPATOPATHY; =4HESEPARADOXICALFINDINGSHAVE BEENEXPLAINEDASBEINGCONSEQUENCESOFBILIARYHYPERPLASIA;=ANDONE STUDYFOUNDAHIGHLYSIGNIFICANTASSOCIATIONBETWEENTHESEVERITYOFBILIARY HYPERPLASIAANDTHESERUMCONCENTRATIONSOF!0ANDa'4;= !LTHOUGH ',$( IS CONSIDERED TO BE LIVER SPECIFIC THIS AUTHOR HAS ENCOUNTERED MANY CASES IN WHICH HIGH ',$( CONCENTRATIONS WERE NOT SUPPORTEDBYLIVERBIOPSYFINDINGS;=4HISMIGHTPOSSIBLYBEEXPLAINEDBY HISTOPATHOLOGICALLYINSIGNIFICANTHEPATICINSULTSRESULTINGININCREASEDSERUM ',$(CONCENTRATIONS4HEPROGNOSTICVALUEOF',$(ISDISPUTED; =

"IOCHEMICALINDICATORSOFHEPATICFUNCTION &URTHER SERUM BIOCHEMICAL TESTS MAY PROVIDE EVIDENCE OF ADEQUATE COM PENSATION VERSUS INSUFFICIENCY OF HEPATIC FUNCTION IN SUSPECTED HEPATITIS CASESANDGENERALLYOFFERGREATERDIAGNOSTICANDPROGNOSTICVALUETHANSERUM ENZYMES ; =4HE MONITORING OF SUBSTANCES THAT ARE USUALLY EXTRACTED FROMSERUMBYTHELIVEREG BILEACIDSANDBILIRUBIN ORWHOSESERUMLEVELS AREMAINTAINEDBYANORMALLYFUNCTIONINGLIVEREG ALBUMIN GLOBULINSAND UREA FORMTHEBASISFORTHESE@FUNCTIONALTESTS3UCHPARAMETERSARELIKELY TOBEMOREEFFECTIVETHANSERUMENZYMESINTHEDIFFERENTIATIONOFCOMPEN SATEDHEPATITISFROMDECOMPENSATEDHEPATICFAILURE4HOSEINMOSTCOMMON USAGE ARE LISTED ABOVE BUT MAY ADDITIONALLY INCLUDE VARIOUS AMINO ACIDS AMMONIA FIBRINOGEN GLUCOSE COAGULATION TESTS ACTIVATED PARTIAL THROM BOPLASTINTIME;!044=ANDPROTHROMBINTIME;04= ANDHALF LIFEOFPLASMA BROMOSULPHTHALENE INDOCYANINEGREENANDRADIONUCLEIDES;  = &AILURE OF NORMAL EXTRACTIVE PROCESSES BY DAMAGED HEPATOCYTES OFTEN LEADSTOINCREASEDSERUMBILEACIDCONCENTRATIONANDTHISISSTRONGLYADVO CATEDASANEXCELLENTDIAGNOSTICANDPROGNOSTICINDICATOROFHEPATICINSUF FICIENCYINTHEHORSE;    =4HEMAINLIMITATIONOFSERUMBILEACID MEASUREMENTISITSINSENSITIVITYANDEARLYORMILDHEPATITISCASESWILLUSUALLY HAVENORMALRESULTS;=)NONESTUDYONLYOF BIOPSYCONFIRMED LIVERDISEASECASESHADINCREASEDSERUMBILEACIDS;=3ERUMBILEACIDCON CENTRATIONSGREATERTHAN+MOLLAREPROGNOSTICALLYCONCERNINGINCHRONIC HEPATOPATHIES ;= AND CASES WITH VALUES ABOVE  +MOLL ARE INVARIABLY FATAL(OWEVER BILEACIDSARELESSPROGNOSTICALLYCONCERNINGINACUTEHEPA TITISCASESANDFARHIGHERLEVELS+MOLL AREOFTENSEENINSUBJECTSTHAT LATERRECOVER 5NCONJUGATEDINDIRECT BILIRUBINISALSOEXTRACTEDFROMPLASMABYFUNC TIONALHEPATOCYTESANDTHENCONJUGATEDPRIORTOBILIARYEXCRETION!NOREXIA ;=ANDHAEMOLYSIS; =AREADDITIONALCAUSESOFUNCONJUGATEDINDIRECT HYPERBILIRUBINAEMIAWITHVALUESINANOREXICSUBJECTSSOMETIMESEXCEEDING +MOLLINTHEABSENCEOFLIVERDISEASE;=4HEMAJORITYOFEQUINELIVER



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DISEASE CASES HAVE NORMAL OR ONLY MODERATE INCREASES IN SERUM BILIRUBIN CONCENTRATION ;  = AND THE UNCONJUGATED FRACTION USUALLY COMPRISES OFTHETOTAL;=CREATINGINTERPRETIVEPROBLEMSINANOREXICSUBJECTS /CCASIONALCASESOFHEPATITISINTHEHORSEINWHICHSERUMCONJUGATEDBILI RUBIN REPRESENTS GREATER THAN  OF TOTAL BILIRUBIN ARE VERY LIKELY TO BE SUFFERINGFROMOBSTRUCTIONOFTHEBILIARYTRACT; = -ARKEDHYPOALBUMINAEMIAGL ISRARELYSEENASARESULTOFHEPATITIS IN HORSES DUE TO THE LONG SERUM HALF LIFE OF ALBUMIN AND THE LARGE RESERVE CAPACITY OF THE LIVER ;     = ALTHOUGH EVEN MILD TO MODERATE HYPOALBUMINAEMIAEG nGL SUGGESTSAGUARDEDPROGNOSIS;  = 3ERUMALBUMINCONCENTRATIONSBELOWGLAREVERYRARELYENCOUNTEREDEVEN INSEVEREHEPATOPATHIESANDSUCHLOWVALUESSHOULDCREATEASUSPICIONOFA MULTISYSTEMICPROCESSEG -%%$ ANDPROTEIN LOSINGENTEROPATHY;= (YPERGLOBULINAEMIA IS A VERY USEFUL DIAGNOSTIC AND PROGNOSTIC TEST IN EQUINE LIVER DISEASE ; = AND MAY RESULT FROM THE SYSTEMIC INFLAMMA TORYRESPONSEASSOCIATEDWITHHEPATITISORPERHAPSFROMSYSTEMICIMMUNO STIMULATION BY INTESTINAL DERIVED ANTIGENIC MATERIAL FOLLOWING LOSS OF THE PROTECTIVE BARRIER OF HEPATIC MONONUCLEAR MACROPHAGES +UPFFER CELLS ;= (YPERGLOBULINAEMIA  GL HAS BEEN DEMONSTRATED TO BE SUPERIOR TOOTHERSERUMBIOCHEMICALPARAMETERSINPREDICTINGNON SURVIVALOFLIVER DISEASECASES;= 4HE LIVER IS THE MAIN SITE OF DETOXIFICATION OF AMMONIA .( AND ITS BIOTRANSFORMATION INTO UREA AND THIS HAS BEEN USED TO EXPLAIN THE ASSO CIATIONOFLOWSERUMUREAANDHYPERAMMONAEMIAWITHLIVERFAILURE; = !LTHOUGH MOST CASES OF LIVER DISEASE HAVE NORMAL SERUM UREA CONCENTRA TIONS ;  = LOW SERUM UREA LEVELS HAVE FREQUENTLY BEEN DESCRIBED IN EQUINEHEPATOPATHIES; =/NESTUDYQUESTIONEDTHEABOVEEXPLANATION OFLOWSERUMUREABYFINDINGNOSIGNIFICANTASSOCIATIONBETWEENSERUMUREA AND.(CONCENTRATIONS;=!NOTHERSTUDYALSOFOUNDLOWSERUMCREATININE TOBEASSOCIATEDWITHSEVERELIVERDISEASEANDPROPOSEDPOLYDIPSIAANDRENAL WASHOUTASACAUSALFACTORINHEPATOPATHYCASESWITHLOWUREAANDCREATININE ;=7HATEVERTHEMECHANISM ITISWELLESTABLISHEDTHATLOWSERUMUREAIS ASSOCIATEDWITHHEPATICINSUFFICIENCYANDHASPROGNOSTICRELEVANCE;= (YPERAMMONAEMIAISAFAIRLYCONSISTENTFINDINGINEQUINESUBJECTSWITH (%;  =ALTHOUGHTHEASSOCIATIONBETWEENPLASMA.(ANDSIGNSOF(% WASONLYOFBORDERLINESIGNIFICANCEINONESTUDY;=!NOTHERINVESTIGATION FOUNDTHATALTHOUGHPLASMA.(CONCENTRATIONWASINCREASEDINNEARLYALL CASESSHOWINGSIGNSOF(% THECONCENTRATIONSVARIEDANDDIDNOTCORRELATE WITHSEVERITYOFTHEDISEASE;=&URTHERMORE OCCASIONALCASESWEREFOUND TOHAVEINCREASEDPLASMA.(WITHOUTSHOWINGSIGNSOF(%;=!DDITIONAL DOUBTS ABOUT THE PATHOGENIC ROLE OF .( IN (% HAVE BEEN RAISED BY THE CONTRASTINGEFFECTSOFEXPERIMENTALLYINDUCEDHYPERAMMONAEMIASUPPORT ING THE VIEW THAT OTHER FACTORS ARE OFTEN INVOLVED IN THE PATHOGENESIS OF (% ; = !DDITIONAL AND SOMETIMES INTERACTING PATHOGENIC ROLES ARE PROPOSED FOR TUMOUR NECROSIS FACTOR _ AROMATIC AMINO ACIDS MANGANESE

(EPATITISINHORSES



COPPER PHENOLS BENZODIAZEPINE LIKE SUBSTANCES MERCAPTANS SHORT CHAIN FATTYACIDS MONOAMINES NEUROSTEROIDS BILIRUBINANDELECTROLYTES;n= !N ALTERNATIVE EXPLANATION OF THE WEAK ASSOCIATION BETWEEN PLASMA .(AND(%ISTHATTHEABILITYOF.(TOCROSSTHEBLOODBRAINBARRIERIS INCREASEDINSUBJECTSWITH(%;  n=/NESTUDYIDENTIFIEDAHIGH CONCENTRATION OF .( IN THE CEREBROSPINAL FLUID OF A HORSE WITH (% ;= !STROCYTICGLUTAMINESYNTHESISFROM.(ISGREATLYINCREASEDIN(%CASES ANDTHEOSMOTICEFFECTOFINCREASEDGLUTAMINEISTHELIKELYULTIMATECAUSEOF ASTROCYTESWELLING AKEYPATHOLOGICALEVENTIN(%;  = (EPATITISANDACUTEPHASEPROTEINS!00S HAVEANUNPREDICTABLEASSO CIATION-OST!00SARESYNTHESISEDBYTHELIVERANDSUBSEQUENTLYDECREASED HEPATIC BIOSYNTHESIS OF FIBRINOGEN HAS OFTEN BEEN REPORTED IN ASSOCIATION WITH EQUINE HEPATITIDES ;  = (OWEVER THE SYSTEMIC INFLAMMA TORYRESPONSEFREQUENTLYSEENINASSOCIATIONWITHHEPATICINSUFFICIENCYEG HYPERGLOBULINAEMIA NEUTROPHILIA TUMOUR NECROSIS FACTOR _ AND MORE ESPECIALLY HEPATITIDES PROVIDES A POSSIBLE EXPLANATION OF THE ASSOCIATION BETWEENHIGHERPLASMAFIBRINOGENANDFAILURETOSURVIVEFOUNDINONESTUDY OF EQUINE HEPATIC DISEASE ;= "ACTERIAL HEPATITIDES SEPTIC CHLOLANGITIS ABSCESSES ETC ARE CERTAINLY EXPECTED TO PROVOKE SIGNIFICANT HEPATIC!00 SYNTHESIS AND HIGHER CONCENTRATIONS OF FIBRINOGEN EG  GL OR SERUM AMYLOID!MGL SUGGESTABACTERIALAETIOLOGY 4HEORETICALLY THE EFFECT OF HEPATIC INSUFFICIENCY ON BLOOD COAGULATION ISHARDTOPREDICTASTHELIVERISTHEMAJORSITEOFSYNTHESISOFMOSTPROCO AGULANT ANTICOAGULANTANDFIBRINOLYTICPROTEINSANDPLATELETDYSFUNCTIONIS ALSOREPORTED;=(OWEVER LABORATORYMEASURESOFHAEMOSTASIS!044 AND04 AREINVARIABLYPROLONGEDINASSOCIATIONWITHHEPATICFAILURE;= !LTHOUGH CLINICOPATHOLOGIC EVIDENCE OF COAGULOPATHY IS SEEN RELATIVELY FREQUENTLYINSEVEREHEPATITISCASES CLINICALSIGNSOFBLEEDINGAREQUITERARE ;  = (EPATICINSUFFICIENCYISASSOCIATEDWITHINCREASEDSERUMCONCENTRATIONS OFMETHIONINEANDAROMATICAMINOACIDSTYROSINE TRYPTOPHANANDPHENYL ALANINE DUETOREDUCEDHEPATICCLEARANCE!SIMILARINCREASEISNOTSEENIN BRANCHEDCHAINAMINOACIDSVALINE LEUCINEANDISOLEUCINE THATCONTINUETO BEMETABOLISEDINOTHERTISSUESSUCHASMUSCLE;=4HEALTEREDBALANCEOF SERUMAMINOACIDSMAYCONTRIBUTETOTHESIGNSOF(%BYLEADINGTOINCREASES IN FALSE NEUROTRANSMITTERS ;= -EASUREMENT OF SERUM AMINO ACIDS DOES NOTAPPEARTOBEPOPULARINEQUINEPRACTICEALTHOUGHITHASAGOODEVIDENCE BASIS; = (EPATIC GLUCONEOGENESIS IS THE MAIN MECHANISM MAINTAINING FASTING EUGLYCAEMIA AND HYPOGLYCAEMIA IS OCCASIONALLY ENCOUNTERED IN ACUTE AND TERMINALHEPATITISCASESPRESUMABLYASARESULTOFFAILUREOFTHISPROCESS;= (OWEVER THIS IS FAR MORE LIKELY TO BE ENCOUNTERED IN FOALS THAN IN ADULT HORSES)NMOSTCLINICALCASESNORMO TOHYPER GLYCAEMIAAREMORECOMMON PERHAPS AS A RESULT OF A STRESS RESPONSE TO ILLNESS WITH ACUTE INSULIN RESIS TANCE;   =



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4HEABILITYOFTHELIVERTOREMOVEEXOGENOUSAGENTSSUCHASBROMOSUL PHTHALENE INDOCYANINEGREENANDRADIOPHARMACEUTICALSFORMSTHEBASISFOR DYNAMICTESTSOFLIVERFUNCTION;  =,OGISTICSOFDYNAMICTESTING ANDLACKOFAVAILABILITYOFTESTINGFACILITIESINCOMPARISONTOEASILYMEASURED ALTERNATIVESABOVE HAVELIMITEDTHEIRUSEANDNONEAREPOPULARINEQUINE PRACTICE 3TUDIESHAVEESTABLISHEDTHEPROGNOSTICIMPORTANCEOFHEPATICFIBROPLA SIAINHORSES;=BUT UNLIKEHUMANMEDICINE NOSERUMMARKERSOFFIBROSIS HAVEBEENINVESTIGATEDINEQUINEHEPATITISCASES(YALURONAN APARAMETER REFLECTINGHEPATICFIBROSISINHUMANS; = HASBEENMEASUREDSUCCESS FULLYINHORSESINEXPERIMENTALSTUDIESOFJOINTANDLUNGDISEASES;=AND MERITSFURTHERINVESTIGATIONINTHECONTEXTOFEQUINELIVERDISEASE

5LTRASONOGRAPHY %XCEPTINRARECASESOFMARKEDHEPATICATROPHY APROPORTIONOFTHEEQUINE LIVERISAMENABLETOTRANSCUTANEOUSULTRASONOGRAPHYUSINGTO-(Z TRANSDUCERS;=4HENORMALLIVERISENTIRELYWITHINTHEBOUNDARIESOFTHE RIBCAGEANDAERATEDLUNGPOSESTHEMAINULTRASONOGRAPHICOBSTRUCTIONAND SIGNIFICANTLY LIMITS THE VALUE OF THE TECHNIQUE IN HORSES4HE LUNG MARGINS REPRESENT THE CRANIO DORSAL LIMITS OF THE HEPATIC IMAGE ON BOTH SIDES )N ALMOSTALLCASES THERIGHTHEMITHORAXALLOWSIMAGINGOFAGREATERQUANTITY OF LIVER OFTEN BETWEEN THE TH AND TH RIBS ALTHOUGH THERE IS CONSIDER ABLEINDIVIDUALVARIATIONINTHENUMBEROFINTERCOSTALSPACESVIAWHICHAN IMAGECANBEOBTAINED4HEIMAGEOFTHERIGHTLIVERLOBEISAPPROXIMATELY TRIANGULAR!HYPERECHOICCURVILINEARIMAGEOFTHERIGHTCOLONDORSALAND VENTRAL IS CONSISTENTLY IMAGED DEEP TO THE RIGHT LIVER LOBE AND A SMALLER MOTILEDUODENUMISFREQUENTLYIMAGEDONTHEMEDIALSURFACEBETWEENTHE LIVERANDCOLONINTHEMORECAUDALINTERCOSTALSPACESEG n /NTHE LEFTSIDELIVERCANONLYUSUALLYBEIMAGEDVIAORINTERCOSTALSPACESIMME DIATELYCAUDALTOTHELEFTVENTRICLE#ARESHOULDBETAKENNOTTOCONFUSETHE HEPATIC IMAGE WITH THE ADJACENT SPLEEN 4HE LATTER IS MORE CAUDAL MORE ECHOGENICANDEXTENDSFROMTHEMEDIALASPECTOFTHELIVERCRANIALLYTOTHE LATERALABDOMINALWALLCAUDALLYOVERMANYMOREINTERCOSTALSPACESTHANTHE RELATIVELYSMALLANDHYPOECHOICLIVER 3TUDIES HAVE ESTABLISHED SIGNIFICANT DIAGNOSTIC AND PROGNOSTIC CLINICAL USEFULNESS OF HEPATIC ULTRASONOGRAPHY ;  = )MAGES CLASSIFIED AS ABNORMALHAVEAHIGHSPECIFICITYFORTHEPRESENCEOFSIGNIFICANTLIVERDISEASE ;= AND ARE ASSOCIATED WITH POORER CLINICAL OUTCOMES ;= ALTHOUGH LOW SENSITIVITYFORDETECTINGLIVERDISEASEISTHEMAINLIMITATIONANDMANYHORSES WITHNORMALULTRASONOGRAPHICHEPATICIMAGESWILLBECONFIRMEDTOHAVESIG NIFICANTLIVERDISEASEINBIOPSYSPECIMENS;=&REQUENTLYSUSPECTEDULTRA SONOGRAPHIC ABNORMALITIES SUCH AS ABNORMAL ECHOGENICITY SIZE AND SHAPE ARE SUBJECTIVELY ASSESSED ALTHOUGH CYSTS CHOLELITHS NEOPLASMS ABSCESSES

(EPATITISINHORSES



HAEMATOMA AND HEPATIC RUPTURE MAY BE MORE OBJECTIVELY DEFINED ;    = )NCREASED HEPATIC ECHOGENICITY HAS BEEN REPORTED PREVIOUSLY IN CASES OF HEPATIC FIBROSIS HAEMOSIDEROSIS AND LIPIDOSIS AND ROUNDING OF HEPATIC MARGINS MAY SUGGEST HEPATOMEGALY ;  = )N THIS AUTHORS VIEW THEMAINVALUEOFHEPATICULTRASONOGRAPHYISASANIMPORTANTADJUNCT TO BIOPSY 5LTRASONOGRAPHIC GUIDANCE ALLOWS MORE CAREFUL SELECTION OF A BIOPSYSITETHATPROBABLYIMPROVESTHESAFETYANDDIAGNOSTICSUCCESSOFTHE BIOPSYPROCEDURESEEBELOW 

,APAROSCOPY 2ARELYHEPATOPATHYCASESARESEENINWHICHNOLIVERTISSUECANBEIMAGED ULTRASONOGRAPHICALLY AND LAPAROSCOPY CAN THEN BE USED TO VISUALISE THE LIVERANDGUIDEBIOPSYCOLLECTION4HISHASPROVENVERYVALUABLEINSEVERAL CASESSEENBYTHISAUTHOR4HEREADERISREFERREDTOSURGICALTEXTSFORFURTHER DESCRIPTIONOFTHETECHNIQUE;=

,IVERBIOPSY )NTHEABSENCEOFNON INVASIVETESTSTHATCANRELIABLYDISTINGUISHHORSESWITH SIGNIFICANT LIVER DISEASE FROM THOSE WITHOUT EVIDENCE OF SIGNIFICANT LIVER DISEASE ;= HISTOPATHOLOGICAL EXAMINATION OF LIVER BIOPSIES HAS BECOME ESTABLISHEDASTHEANTEMORTEMTESTOFGREATESTVALUEINCOMMONUSAGE; =(ISTOPATHOLOGICASSESSMENTOFBIOPSYSPECIMENSISOFGREATPROGNOSTIC VALUEANDGUIDESTHECHOICEOFSPECIFICTHERAPYININDIVIDUALCASES)TISALSO THE DIAGNOSTIC TECHNIQUE MOST LIKELY TO PROVIDE A SPECIFIC DIAGNOSIS AND AETIOLOGICINFORMATION!DDITIONALLY GIVENTHELACKOFABSOLUTERELIABILITYOF SERUM BIOCHEMICAL DATA WHEN MONITORING RESPONSE TO TREATMENT IN HEPA TITIS CASES REPEAT BIOPSY MAY BE THE BEST TECHNIQUE TO ESTABLISH ADEQUATE RECOVERYAND INDEED THEPRESENCEORABSENCEOFFURTHERSECONDARYCHANGES FOLLOWINGINITIALBIOPSY ,IVERBIOPSYISANEASY SAFEANDHIGHLYINFORMATIVEDIAGNOSTICPROCEDURE IN CASES OF SUSPECTED HEPATITIS ; =!LTHOUGH ADVERSE EFFECTS SUCH AS HAEMORRHAGE COLIC PERITONITIS PLEURITISANDPNEUMOTHORAXAREALLREPORTED ;= THESEPROBLEMSAREVERYRARELYENCOUNTERED4HEIMPORTANCEANDUSE FULNESSOFTHEINFORMATIONOBTAINEDBYBIOPSYINVARIABLYOUTWEIGHSTHEASSO CIATEDRISKSINTHISAUTHORSVIEW ESPECIALLYWHENTHETECHNIQUEISPERFORMED UNDER ULTRASONOGRAPHIC GUIDANCE !LTHOUGH MANY RECOMMEND PRE BIOPSY COAGULATIONASSESSMENT;  = THEREQUIREMENTFORTHISISQUESTIONABLE ;=/NESTUDYREPORTEDSIGNSOFINTRA ABDOMINALHAEMORRHAGEATAUTOPSY FOLLOWINGLIVERBIOPSYINTHREEHORSESWITHPROLONGEDCLOTTINGTIMESALTHOUGH QUANTITYANDASSOCIATEDCLINICALSIGNSWERENOTDESCRIBED;=!FURTHERREPORT DESCRIBEDASINGLECASEOFPOST BIOPSYHAEMORRHAGEOUTOFLIVERBIOPSIESIN



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4ABLE  3UMMARY OF SCORES ASSIGNED TO THE SEVERITY OF FIVE HISTOPATHOLOGICAL CRITERIA CON TRIBUTINGTOATOTAL PROGNOSTIC LIVER BIOPSY SCORE MINIMUM SCORE   MAXIMUM SCORE   )RREVERSIBLECYTOPATHOLOGYNECROSIS MEGALOCYTOSISORAMYLOIDOSIS ;= SEVERITY MILD

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CLOUDYCHANGEORCYTOPLASMICGRANULARITYOFHEPATOCYTESAFFECTINGOF AREPRESENTATIVELOBULE;= !POTENTIALMAJORCAUSEOFINSENSITIVITYOFLIVERBIOPSYISTHECOLLECTION OFANUNREPRESENTATIVESPECIMENOFLIVER4HISISILLUSTRATED FOREXAMPLE IN REPORTSOFEIGHTCASESOFHEPATICNEOPLASIAOUTOFWHICHONLYTHREESHOWED EVIDENCEOFTUMOURDEPOSITSINLIVERBIOPSYSPECIMENS;   = AND ONEWASINITIALLYMISDIAGNOSEDASCHOLANGIOHEPATITIS;=(OWEVER THISIS NOTACOMMONSCENARIOANDOTHERSHAVEFOUNDTHATALMOSTALLSERIOUSEQUINE HEPATICDISEASEAFFECTSTHELIVERDIFFUSELYANDTHECORRELATIONBETWEENHIS TOPATHOLOGICFINDINGSINBIOPSYSPECIMENSANDSUBSEQUENTAUTOPSYMATERIAL ISEXCELLENT; = &IBROSIS IS A COMMON AND NON SPECIFIC RESPONSE TO LIVER INJURY ;= AND ALTHOUGH USUALLY ASSOCIATED WITH CHRONIC HEPATOPATHIES FIBROSIS HAS BEEN DETECTED AS SOON AS  DAYS FOLLOWING ACUTE HEPATIC INSULTS IN HORSES ;= -ARKED PERIPORTAL AND BRIDGING FIBROSIS IDENTIFIED IN BIOPSY SPECI MENSHAVELONGBEENREGARDEDASPOORPROGNOSTICINDICATORS; =AND A MORE RECENT STUDY CONFIRMED FIBROSIS AS THE SINGLE MOST PROGNOSTICALLY RELEVANT HISTOPATHOLOGIC VARIABLE ;= (OWEVER IN A PUBLISHED SERIES OF CHOLANGIOHEPATITIS CASES LONG TERM SURVIVAL OF THREE HORSES FOUND TO HAVE SEVEREPERIPORTALANDBRIDGINGFIBROSISWASDESCRIBEDSUGGESTINGTHATOTHER FACTORSAREALSOPROGNOSTICALLYIMPORTANT;=!SCORINGSYSTEMWASTHERE FORE DEVELOPED IN ORDER TO ATTEMPT TO ATTRIBUTE A PROGNOSTICALLY USEFUL BROADINDEXOFHISTOPATHOLOGICSEVERITYCOMPRISINGSEVERALHISTOPATHOLOGIC VARIABLES COMPRISING FIBROSIS BILIARY HYPERPLASIA MEGALOCYTOSIS NECROSIS AMYLOIDOSIS INFLAMMATORYINFILTRATESANDHAEMOSIDEROSIS;=!PPLICATION OF THIS PROGNOSTIC BIOPSY SCORE 4AB  INDICATED A VERY GOOD PROGNOSIS WITHSCORESOFnSURVIVAL AGUARDEDPROGNOSISWITHSCORESOFn SURVIVAL ANDAPOORPROGNOSISWITHSCORESOFnSURVIVAL ;= "IOPSIESSCOREDINTHEHIGHESTCATEGORY WEREASSOCIATEDWITHA TIMESINCREASEDRISKOFDEATHWITHINMONTHSREPRESENTINGAFARHIGHERRISK FACTORTHANANYNON INVASIVETESTRESULTS; =



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$IFFERENTIALDIAGNOSES (EPATITIS CASES RARELY PRESENT WITH ABSOLUTELY SPECIFIC CLINICAL SIGNS AND THEREFORE DIFFERENTIAL DIAGNOSES SHOULD ALWAYS BE CONSIDERED 4HE MAIN PRESENTINGSIGNSOFHEPATITISINHORSESARENON SPECIFICANDCOMPRISECOLIC DEPRESSION NEUROLOGICSIGNSANDWEIGHTLOSS;   =#OLICANDDIAR RHOEA IS A COMMON CLINICAL SIGN OF BOTH ENTERITIDES AND HEPATITIDES AND PYREXIAMAYALSOBEAFEATUREOFBOTH$IFFERENTIALDIAGNOSESOFACUTECEN TRALNEUROLOGICSIGNS;=PRIMARILYCOMPRISEHEPATICFAILURE ENCEPHALITIDES ;= NEUROTOXINSEG MOXIDECTIN FLUPHENAZINE ; = TRAUMA;= AND PRIMARY INTESTINAL HYPERAMMONAEMIA ; = #LINICAL SIGNS COM MONLYOBSERVEDTHATAREMORESUGGESTIVEOFHEPATITISINCLUDEPHOTOSENSITI SATIONANDJAUNDICEALTHOUGHINPRACTICEMOSTHORSESSEENWITHTHESESIGNS WILLHAVENORMALLIVERSWITHPRIMARYPHOTODERMATITISANDANOREXIARESPEC TIVELYBEINGTHECOMMONESTCAUSESOFTHESESIGNS )NMOSTCASESSERUMBIOCHEMISTRYWILLPROVIDETHESTRONGESTINITIALEVI DENCEOFHEPATITISALTHOUGHCASESOFPRIMARYINTESTINALDISEASEARESOMETIMES SEEN WITH MILD TO MODERATE INCREASES IN LIVER DERIVED ENZYMES ;n= 4HISCOULDBECAUSEDBYHEPATICPORTALTRANSFEROFNOXIOUSSUBSTANCESSUCH AS LIPOPOLYSACCHARIDES FROM COMPROMISED INTESTINAL MUCOSAE OR PERHAPS FROMPRESSUREFROMADILATEDSTOMACHORCOLON!DDITIONALCONFUSIONMAY ARISEINSOMECASESASARESULTOFLACKOFABSOLUTESENSITIVITYANDSPECIFICITY OFLABORATORYINDICESOFHEPATITIS;=ANDBIOPSYWILLBEREQUIREDINORDERTO MAKEACERTAINDIAGNOSISOFHEPATITIS4HISAUTHORHASSEENSEVERALSUBJECTS WITHACUTENEUROLOGICSIGNSCAUSEDBY(%THATWEREMISDIAGNOSEDASTRAU MATICCRANIALINJURIESONTHEBASISOFEVIDENCEOFEXTERNALSKINABRASIONSTHAT ACTUALLYRESULTEDFROMFALLSCAUSEDBY(%

4REATMENT 'ENERAL AND SUPPORTIVE CARE CAN BE SUPPLIED FOR ANY SUBJECT SUSPECTED TO BE SUFFERING FROM HEPATITIS INCLUDING FLUID THERAPY AND ANTIPYRETICS BUT SPECIFIC THERAPY CANNOT BE LOGICALLY APPLIED IN THE ABSENCE OF A CLEAR SPE CIFICDIAGNOSIS!LTHOUGHBIOPSYISUSUALLYAPREREQUISITE CERTAINCONDITIONS SUCHASSERUMHEPATITIS CHOLELITHIASISAND4YZZERSDISEASEMAYBESTRONGLY SUSPECTEDONTHEBASISOFHISTORY CLINICALSIGNS ULTRASONOGRAPHYANDSERUM BIOCHEMISTRY)NPRACTICEMANYHEPATITISCASESMAYNOTBECLEARLYREPRESEN TATIVEOFTHECLEARCATEGORICALAETIOLOGICDIAGNOSESDESCRIBEDABOVEEVENFOL LOWINGBIOPSY;=.EVERTHELESSINTUITIVELYINDICATEDTHERAPYCANBEAPPLIED SUCH AS ANTIBACTERIALS IN CASES OF PREDOMINANTLY NEUTROPHILIC HEPATITIDES OR GLUCOCORTICOIDS IN CASES OF PREDOMINANTLY LYMPHOCYTIC EOSINOPHILIC OR PLASMACYTICHEPATITIDES3URGICALMANAGEMENTOFSOMECONDITIONSHASBEEN REPORTED;=ALTHOUGHTHEMAJORITYOFEQUINEHEPATITIDESWILLBEMANAGED MEDICALLY

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!NTIMICROBIALDRUGSAREINDICATEDINALLCASESOFBACTERIALHEPATITISEG CHOLANGIOHEPATITIS CHOLELITHIASIS HEPATICABSCESSATIONAND4YZZERSDISEASE ;  ="ACTERIALISOLATIONANDSENSITIVITYTESTINGISIDEALALTHOUGHWILL INTRODUCE A DELAY IN THERAPY AND MAY OFTEN BE UNPRODUCTIVE OR POTEN TIALLY MISLEADING WHEN BIOPSY SPECIMENS ARE SUBMITTED FOR CULTURE ;= )NTUITIVE PREDICTION OF INDICATED SPECTRA OF ACTIVITY MAY BE APPROPRIATE IN MANY CASES #LOSTRIDIAL HEPATITIS EG 4YZZERS DISEASE SHOULD BE TREATED AGGRESSIVELY WITH SODIUM BENZYL PENICILLIN   IUKG IV QID OR OXYTET RACYCLINE MGKG IV BID  3UPPURATIVE HEPATITIS IN ADULT HORSES USUALLY INVOLVES ENTERIC BACTERIA AND THEREFORE 'RAM NEGATIVE POTENCY IS IMPOR TANT(OWEVER ANAEROBICAND'RAMPOSITIVEPATHOGENSAREWELLRECOGNISED SUGGESTINGTHATBROADSPECTRUMCOVERISADVISABLE0ROLONGEDANTIBACTERIAL THERAPYINEXCESSOFWEEKSISUSUALLYREQUIREDINCHOLANGIOHEPATITISCASES ;= WHICH OFTEN PRECLUDES PARENTERAL THERAPY AND RESTRICTS THE CHOICE OF AVAILABLEPRODUCTS0OTENTIATEDSULPHONAMIDESMGKGCOMBINEDPRODUCT PEROSBID DOXYCYCLINEMGKGPEROSSID BID ANDRIFAMPINMGKGPER OSBID HAVEBROADSPECTRUMACTIVITYALTHOUGHTHELATTERDRUGSHOULDONLY BEUSEDINCOMBINATIONWITHANOTHERANTIBACTERIAL%RYTHROMYCINMGKG PEROSTID HASBEENUSEDSUCCESSFULLYINADULTHORSESALTHOUGHMAYPOSEAN UNACCEPTABLE RISK OF COLITIS ;= %NROFLOXACIN  MGKG PER OS 3ID HAS LIMITED'RAMPOSITIVEANDNEGLIGIBLEANAEROBICACTIVITY WHEREASTHEACTIVITY OFMETRONIDAZOLEMGKGPEROSLOADINGDOSEFOLLOWEDBYMGKGPER OSQID ISRESTRICTEDTOANAEROBICPATHOGENSONLY ,IVER FLUKE &ASCIOLA HEPATICA IS A RARE CAUSE OF HEPATITIS IN HORSES AND DONKEYSBUTHASBEENTREATEDSUCCESSFULLYWITHTRICLABENDAZOLEATADOSEOF MGKGPEROS; =%CHINOCOCCUSGRANULOSUSHYDATID CYSTSAREMORE FREQUENTLYENCOUNTEREDBUTTHEIRPATHOGENICRELEVANCEISOFTENQUESTIONABLE UNLESSLARGENUMBERSAREPRESENTORINTERVENINGHEPATICPARENCHYMAISSHOWN TOBEDISEASED4HISAUTHORHASTREATEDSUCHCASESWITHALBENDAZOLEMGKG PEROSSIDFORDAYSREPEATEDSIXTIMESAT WEEKINTERVALS;=ANDALSOBY CYSTASPIRATIONANDINJECTIONOFSTERILESATURATEDSALINEINTOTHECYSTCAVITY 'LUCOCORTICOIDSAREINDICATEDINCASESOFEOSINOPHILICORLYMPHOPLASMA CYTICHEPATITISANDFORHEPATITIDESWITHSIGNIFICANTFIBROPLASIAEG CHRONIC ACTIVEHEPATITIS 0REDNISOLONEATADOSEOFnMGKGPEROSSIDFORATLEAST  WEEKS IS USUALLY CHOSEN ALTHOUGH MORE AGGRESSIVE THERAPY WITH DEXA METHASONEATTOMGKGIVSIDORONALTERNATEDAYSMAYBEINDICATED INMORESEVEREORNON RESPONSIVECASES$ESPITECOMMONANECDOTALLYHELD VIEWSTOTHECONTRARY HEPATICFIBROSISISAPOTENTIALLYREVERSIBLECHANGEAND EXISTS AS A DYNAMIC BALANCE OF FIBROPLASIA AND FIBRINOLYSIS CONTROLLED BY HEPATICSTELLATECELLS(3#S ;=4HEANTIINFLAMMATORYEFFECTOFGLUCOCOR TICOIDSONACTIVATED(3#SISTHEONLYCOMMONLYAPPLIEDANTIFIBROTICSTRATEGY IN EQUINE HEPATITIS CASES .ON STEROIDAL ANTIINFLAMMATORY DRUGS ARE ONLY USUALLYUSEDINPYREXICHEPATITISCASESSUCHASSEPTICCHOLANGIOHEPATITISAND CHOLELITHIASISEG &LUNIXINMEGLUMINEMGKGSID BID ALTHOUGHBENEFITS INCASESOF(%HAVEBEENPROPOSED;=



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3EVERALPREVIOUSSTUDIESHAVEREPORTEDTHAT(%ISAPOORPROGNOSTICSIGN INHORSES;   =(OWEVER THEFINDINGTHATOFHORSESSHOWING SIGNSOF(%DIDSURVIVEFORATLEASTMONTHSINONESTUDY;=DOESJUSTIFY ATTEMPTSATTREATMENTESPECIALLYINCASESOFACUTEHEPATITISANDDECOMPENSA TION/CCASIONALLYINSTANCESOFEXCITABLEORAGGRESSIVE(%WARRANTSSEDATION WITH SLIGHTLY REDUCED DOSES OF COMMONLY USED SEDATIVES AND TRANQUILISERS EG 8YLAZINEMGKGIV$ETOMIDINE+GKGIV!CEPROMAZINE+GKG IV $IAZEPAMMAYBECONTRAINDICATEDDUETOTHEPROPOSEDINVOLVEMENTOF BENZODIAZEPINE LIKESUBSTANCESINTHEPATHOPHYSIOLOGYOF(%;= 4HEREISLITTLEEVIDENCEBASISFORTHESELECTIONOFTHERAPEUTICAGENTSFOR TREATMENTOF(%ANDSELECTIONISLARGELYBASEDONPERSONALANECDOTALEXPERI ENCE4HISAUTHORGENERALLYFAVOURSLACTULOSEMLKGPEROS WHICHCANBE GIVENINITIALLYEVERYnHIN(%CASESANDREDUCEDINFREQUENCYACCORDING TORESPONSE$IARRHOEAISARARECOMPLICATION&AILURETOCLINICALLYIMPROVE WITHIN n H OF LACTULOSE TREATMENT REFLECTS A POOR PROGNOSIS IN CHRONIC HEPATITISCASESALTHOUGHSUBJECTSWITHACUTEHEPATITISAND(%MAYIMPROVE MORE SLOWLY ,ACTULOSE IS A NON ABSORBABLE INDIGESTIBLE DISACCHARIDE THAT ISMETABOLISEDBYCOLONICBACTERIATOACETICANDLACTICACIDS THUSREDUCING LUMINALP(4HISCOLONICACIDIFICATIONISASSOCIATEDWITHREDUCEDABSORPTION OFIONISEDAMMONIUM SUPPRESSIONOFFAECALUREASEANDPROTEASES INCREASED BACTERIAL.(UTILISATIONANDDEATHOFMANYPROTEOLYTICBACTERIA; = 4HEAUTHORSOFONESTUDYSUGGESTEDTHATORALANTIBIOTICSHADASUBJECTIVELY BETTER INFLUENCE ON (% THAN LACTULOSE ALTHOUGH LONG TERM THERAPY IS LESS SUITABLE WITH ANTIBACTERIALS THAN LACTULOSE ;= .EOMYCIN  MGKG PER OS QID ORMETRONIDAZOLEMGKGPEROSLOADINGDOSEFOLLOWEDBYMGKG PEROSQID HAVEBOTHBEENWIDELYUSEDINEQUINE(%CASESEITHERALONEORIN COMBINATIONWITHLACTULOSE/THERPRODUCTSSUCHAS, ORNITHINE , ASPARTATE MAY BE WORTHY OF INVESTIGATION IN EQUINE (% CASES4HIS PRODUCT REDUCES PLASMA.(CONCENTRATIONBYPROMOTINGBIOTRANSFORMATIONINTOUREAAND GLUTAMINE IN OTHER TISSUES SUCH AS INTESTINE MUSCLE AND KIDNEY AND HAS A GOODEVIDENCEBASISINHUMANMEDICINE; =

$IETARYMANAGEMENT 3UBJECTSSUFFERINGFROMHEPATITISANDHEPATICINSUFFICIENCYMAYBENEFITFROM SPECIFICNUTRITIONALADVICE7EIGHTLOSSISACOMMONFEATUREOFHEPATICINSUF FICIENCYANDAFFECTEDSUBJECTSTENDTOCATABOLISEBODILYPROTEINMOREREADILY THANHEALTHYSUBJECTS; =!DEQUATEDIETARYDIGESTIBLEENERGYINTAKE K*KGDAY;= ISESSENTIALBUTMAYBEHARDTOMAINTAININANORECTIC SUBJECTS "ALANCED PARENTERAL NUTRITION HAS BEEN SUCCESSFULLY SUPPLIED BY THISAUTHORTOHORSESWITHACUTEHEPATICFAILURECOMPRISINGEQUALVOLUMESOF GLUCOSE AMINOACIDS)NTRAFUSIN &RESENIUS+ABI ANDLIPID EMULSION)NTRALIPID &RESENIUS+ABI ATARATEOFMLKGHOUR%XCESS DIETARYPROTEINMIGHTINCREASEAMMONIAGENESISANDPRECIPITATE(%WHEREAS

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!BSTRACT 3INCE DISCOVERY OF THE HEPATITIS " VIRUS ("6 CLOSELY RELATED VIRUSES HAVE BEEN DESCRIBED IN SEVERAL ANIMAL SPECIES 4HE FIRST OF THESE WAS THE WOODCHUCK HEPATITIS VIRUS 7(6 IDENTIFIED IN WOODCHUCKS -ARMOTA MONAX THAT WERE MAINTAINED AT THE 0HILADELPHIA :OOLOGICAL 'ARDEN AND WHICH HAD EXPERIENCED A HIGH PREVALENCE OF CHRONIC HEPATITIS AND HEPATOCELLULAR CARCINOMA (##  /N THE BASIS OF MORPHOLOGICAL ANDMOLECULARANALYSES ITWASCONCLUDEDTHAT7(6WASCLOSELYRELATEDTO("63INCE DESCRIPTION OF 7(6 INFECTION WITH VIRUSES THAT BELONG TO THE FAMILY (EPADNAVIRIDAE HAVEBEENDESCRIBEDINTHE#ALIFORNIAGROUNDSQUIRREL3PERMOPHILUSBEECHEYI ANDTHE !RCTICGROUNDSQUIRREL3PERMOPHILUSPARRYI TWOSPECIESCLOSELYRELATEDPHYLOGENETICAL LYTOWOODCHUCKS ANDINSIXAVIANSPECIES!TOTALOFFOURWELLCHARACTERIZED MAMMALIAN HEPADNAVIRUSESNOWHAVEBEENASSOCIATEDWITHDEVELOPMENTOF(##4HESEOBSERVATIONS ONNATURALLYACQUIREDHEPADNAVIRUSINFECTIONSCOMBINEDWITHTHEDEVELOPMENTOF(## INWOODCHUCKSFOLLOWINGEXPERIMENTALINFECTIONWITH7(6ORWITHTHE#ALIFORNIAGROUND SQUIRRELVIRUS'3(6 PROVIDES BYANALOGY CONVINCINGCOMPARATIVEMEDICALEVIDENCEFOR THEHEPATOCARCINOGENICITYOF("64HEWOODCHUCKHASBECOMEUSEFULASANEXPERIMENTAL ANIMALMODELFORRESEARCHONTHEPATHOGENESISOF("6INFECTIONANDFORINVESTIGATIONOF THEMOLECULARMECHANISMSOFHEPATOCARCINOGENESIS4HEWOODCHUCKALSOHASBEENUSEFUL IN THE DISCOVERY AND PRECLINICAL DEVELOPMENT OF ANTIVIRAL DRUGS FOR TREATMENT OF ("6 INFECTIONANDFORTESTINGNEWFORMSOFIMMUNOTHERAPYUSINGCYTOKINESANDTHERAPEUTIC VACCINATION)NPARTICULAR THEWOODCHUCKHASBEENVALUABLEFORDETERMININGTHEIMPACT OF LONG TERM ANTIVIRAL TREATMENT ON THE OUTCOME OF CHRONIC HEPADNAVIRUS INFECTION IN PLACEBOCONTROLLED LIFETIMESURVIVALSTUDIESWHICHHAVEBEENPREDICTIVEOFTHERESULTSOF SUBSEQUENTCLINICALTRIALS

)NTRODUCTION )DENTIFICATIONOFTHEVIRUSOFHEPATITIS"("6 WASONETHEMOSTIMPORTANT MEDICALADVANCESOFTHETH#ENTURYANDHASLEDTOSIGNIFICANTADVANCESIN THEDIAGNOSIS TREATMENT CONTROLANDPREVENTIONOFONEOFTHEWORLDSMOST WIDESPREAD AND DEVASTATING INFECTIOUS DISEASES 3INCE DISCOVERY OF ("6



"UD#4ENNANTETAL

CLOSELYRELATEDVIRUSESHAVEBEENDESCRIBEDINSEVERALMAMMALIANANDAVIAN SPECIES0ROF(EINZ3CHALLER TOWHOMTHISVOLUMEISDEDICATED HASUTILIZED NATURALLYOCCURRINGANIMALMODELSTOINVESTIGATETHEPATHOGENESISOF("6 INFECTION AND THE MECHANISMS OF ("6 REPLICATION )N SO DOING HE HAS IN SIGNIFICANTWAYSENHANCEDOURUNDERSTANDINGOFTHEPATHOGENESISOF("6 INFECTION HAS IMPROVED THE CARE OF PATIENTS INFECTED WITH ("6 AND HAS TRAINEDSOMEOFTHEMOSTDISTINGUISHEDMEMBERSOFTHECURRENTGENERATION OFHEPATITISVIROLOGISTS(ISRESEARCHWITHANIMALMODELSYSTEMSREPRESENTS ANIMPRESSIVECONTRIBUTIONTOMODERNCOMPARATIVEMEDICINE

.ATURALHISTORYOFWOODCHUCKHEPATITISVIRUSINFECTION 4HEWOODCHUCKHEPATITISVIRUS7(6 WASDESCRIBEDORIGINALLYBY3UMMERS ANDCOLLEAGUESINACOLONYOFWOODCHUCKS-ARMOTAMONAX MAINTAINEDAT THE 0HILADELPHIA :OOLOGICAL 'ARDEN AND THAT FOR SOME YEARS HAD EXPERI ENCEDANUNUSUALLYHIGHRATEOFCHRONICHEPATITISANDHEPATOCELLULARCARCI NOMA(## ;=/NTHEBASISOFMORPHOLOGICALANDMOLECULARANALYSES IT WASCONCLUDEDTHAT7(6WASCLOSELYRELATEDTOTHEHEPATITIS"VIRUS("6 FAMILYOFVIRUSESANDTHEWOODCHUCKHEPATITISVIRUS7(6 NOWISCLASSI FIEDASAMEMBEROFTHEFAMILY(EPADNAVIRIDAE GENUS/RTHOHEPADNAVIRUS OFWHICHTHEPROTOTYPEMEMBERIS("64AB  4HE NATURAL HABITAT OF THE WOODCHUCK EXTENDS FROM NORTH 'EORGIA !LABAMA AND-ISSISSIPPIINTHESOUTHERN5NITED3TATES WESTTO/KLAHOMA +ANSAS .EBRASKA AND)OWA NORTHTO1UEBECAND,ABRADOR ACROSS#ANADA TO "RITISH #OLUMBIA AND THE 9UKON 4ERRITORY AND INCLUDES AN AREA OF SOUTHEASTERN!LASKA! COMPREHENSIVE SEROEPIDEMIOLOGIC STUDY OF7(6 INFECTIONTHROUGHOUTTHISRANGEHASNEVERBEENPERFORMED7(6INFECTION IS KNOWN TO BE HYPERENDEMIC IN THE MID !TLANTIC REGION OF THE 5NITED 3TATESANDTHEWOODCHUCKSSTUDIEDORIGINALLYBY3UMMERSETALWEREFROM 0ENNSYLVANIA ;= )N SUBSEQUENT STUDIES REPORTED BY 4YLER ET AL ;=  OF THE WOODCHUCKS FROM 0ENNSYLVANIA .EW *ERSEY AND -ARYLAND TESTED POSITIVEFORTHE7(6SURFACEANTIGEN7(S!G ANDWEREPOSITIVEFOR ANTIBODYTOTHE7(6SURFACEANTIGENANTI 7(S FORAOVERALLRATEOF INFECTION3IMILARHIGHRATESOF7(6INFECTIONHAVEBEENCONFIRMEDBYOTH ERSINWOODCHUCKSFROMTHE-ID !TLANTIC3TATES;=)NCONTRAST THEPREVA LENCE OF7(6 INFECTION IN CENTRAL .EW9ORK 3TATE IS APPROXIMATELY  BASEDONTHEDETECTIONOFANTI 7(SANTIBODY;=ANDTHERATEOFPERSISTENT 7(SANTIGENEMIAISESTIMATEDTOBELESSTHAN!LTHOUGHTHENUMBER OFWOODCHUCKSTESTEDISSMALL NOSEROLOGICEVIDENCEOF7(6INFECTIONHAS BEENFOUNDIN6ERMONTAND-ASSACHUSETTS;n=3IMILARLY WEHAVEFOUND WOODCHUCKS FROM )OWA TO BE ANTI 7( CORE ANTIBODY ANTI 7(C NEGA TIVE7EHAVE HOWEVER EXAMINEDHEPATICTISSUESOFWOODCHUCKSFROMTHE 0ROVINCEOF1UEBECAND/HIOTHATDIEDOFHEPATOCELLULARCARCINOMA(##  .ON NEOPLASTIC LIVER TISSUE WAS EXAMINED IMMUNOHISTOLOGICALLY FOR THE

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"UD#4ENNANTETAL

SIGNIFICANT NUMBERS OF INFILTRATING HEMATOPOIETIC CELLS AND PROGRESSION OF NEOPLASIAFROMFOCIOFALTEREDHEPATOCYTESTOSMALLNEOPLASTICNODULESAND TO FRANK (## WAS RECOGNIZED ;= -ETASTASIS OF (## OUTSIDE THE LIVER WHICHOCCURSINHUMANSANDOTHEREXPERIMENTALANIMALMODELSWITHSOME FREQUENCY HASNOTBEENOBSERVEDINWOODCHUCKSWITH(##BYMOSTINVES TIGATORSALTHOUGHPULMONARYMETASTASESHAVEBEENREPORTED;=

/THERNATURALLYOCCURRINGHEPADNAVIRUSINFECTIONS (EPADNAVIRUSES CLOSELY RELATED TO ("6 AND 7(6 HAVE BEEN REPORTED IN OTHER MAMMALIAN AND AVIAN SPECIES 4AB  AND THE MORPHOLOGY AND GENETICORGANIZATIONOFTHESEHEPADNAVIRUSESARESIMILAR;n=#ALIFORNIA GROUNDSQUIRRELS3PERMOPHILUSBEECHEYI ARETHEHOSTSPECIESOFTHEGROUND SQUIRRELHEPATITISVIRUS'3(6 ;n=#HRONIC'3(6INFECTIONISASSOCI ATEDWITHCHRONICHEPATITISANDWITH(## ALTHOUGHTHEFREQUENCYOF(## IS REMARKABLY LESS THAN THAT ASSOCIATED WITH CHRONIC 7(6 INFECTION AND DEVELOPSINMUCHOLDERANIMALS; n= 4HEARCTICGROUNDSQUIRRELHEPATITISVIRUS!'3(6 HASBEENREPORTED INTHEARCTICGROUNDSQUIRREL3PERMOPHILUSPARRYI ANDINFECTIONALSOWAS ASSOCIATED WITH (## ;= )NFECTION WITH A PUTATIVE HEPADNAVIRUS WAS DESCRIBED IN %ASTERN GRAY SQUIRRELS 3PERMOPHILUS CAROLINENSIS FROM THE 3TATEOF0ENNSYLVANIA;=INWHICHLESIONSOFHEPATITISWEREOBSERVEDBUT HEPATICTUMORSWERENOTREPORTED(EPADNAVIRUSINFECTIONIN2ICHARDSONS GROUNDSQUIRRELS3PERMOPHILUSRICHARDSONII ORIGINATINGINTHE0ROVINCEOF !LBERTAHASBEENREPORTED; = 4HE HEPATIC LESIONS INCLUDING (## IN 2ICHARDSONS GROUND SQUIRRELS WERESIMILARTOTHOSEDESCRIBEDINWOODCHUCKS #ALIFORNIAGROUNDSQUIRRELS AND!RCTICGROUNDSQUIRRELS;= $UCK HEPATITIS " VIRUS $("6 HAS BEEN REPORTED IN DOMESTIC 0EKIN DUCKS!NASDOMESTICUS ANDHASAWORLDWIDEDISTRIBUTION;n=3IMILAR AVIANHEPADNAVIRUSESALSOHAVEBEENDESCRIBEDINGREYHERONS!RDEACINE REA HERON HEPATITIS " VIRUS ;= AND IN SNOW GEESE !NSER CAERULESCENS ;= -UCH OF THE CURRENT UNDERSTANDING OF HEPADNAVIRUS REPLICATION IS BASEDONRESEARCHUSING$("6INVIVOANDINVITRO; =(##HASBEEN INFREQUENTLYASSOCIATEDWITH$("6INFECTION;=ANDTHEHEPATOCARCINO GENICITYOF$("6INDUCKSREMAINSQUESTIONABLE(EPATICNEOPLASMSHAVE NOTBEENASSOCIATEDWITHHERONHEPATITIS"VIRUSINFECTION;=

%XPERIMENTALWOODCHUCKHEPATITISVIRUSINFECTION 7OODCHUCKSWITHNATURALLYACQUIRED7(6INFECTIONWEREVALUABLESOURCES OFVIRUSANDHEPATICTISSUEFORHISTOLOGICALANDMOLECULARANALYSES4HEIRUSE EXPERIMENTALLY HOWEVER WAS LIMITED BECAUSE IT WAS IMPOSSIBLE TO KNOW

4HEWOODCHUCKMODELOFHEPADNAVIRUSINFECTION



WHENANDFORHOWLONGTRAPPEDWOODCHUCKSHADBEENINFECTEDWITH7(6 ORTOKNOWTHENUTRITIONALHISTORYORTHEIREXPOSURETOOTHERENVIRONMENTAL FACTORS THAT MIGHT INFLUENCE THE OUTCOME OF7(6 INFECTION )MPORTANTLY HEPATIC LESIONS CAUSED BY NEMATODES SUCH AS !CKERTIA MARMOTAE AND #APILLARIASPWERECOMMONINWILDWOODCHUCKS;=ANDCOULDCOMPLICATE THEINTERPRETATIONOFEXPERIMENTALRESULTS 3UMMERSANDCOLLEAGUES;=DESCRIBEDTHEEXPERIMENTALINFECTIONOF TO MONTHOLDWOODCHUCKSWITHSERUMFROMCHRONIC7(6CARRIERS4HEY DESCRIBED PRODUCTIVE SELF LIMITED INFECTION BUT NO WOODCHUCKS BECAME CHRONIC7(6CARRIERS!TTEMPTSBYOTHERSTOEXPERIMENTALLYINFECTJUVENILE ORADULTWOODCHUCKSALSORESULTEDINACUTE7(6INFECTION;  =BUT WITHONEEXCEPTION DIDNOTCAUSECHRONICINFECTION -ORPHOLOGIC AND MOLECULAR VIROLOGICAL STUDIES OF THE LIVER OF WOOD CHUCKSEXPERIMENTALLYINFECTEDWITH7(6HAVESHOWNTHATVIRTUALLY OF HEPATOCYTES BECOME INFECTED FOLLOWING EXPERIMENTAL 7(6 INFECTION ;=!LTHOUGHREPLICATIVEFORMSWERECLEAREDRAPIDLYDURINGRECOVERY COVA LENTLYCLOSEDCIRCULAR7(6$.!PERSISTEDINTHREEOFWOODCHUCKSAFTER EVIDENCE OF7(6 REPLICATION HAD CEASED ;= #LEARANCE OF EXPERIMENTAL 7(6 INFECTION IN ADULT WOODCHUCKS WAS ASSOCIATED WITH ROBUST HUMORAL ANDCELL MEDIATEDIMMUNERESPONSES;n=4REATMENTWITHIMMUNESUP PRESSIVEDOSESOFCYCLOSPORINE!SIGNIFICANTLYINCREASEDTHERATEOFCHRONIC ITYFOLLOWINGEXPERIMENTAL7(6INFECTIONOFADULTWOODCHUCKS; = 7HENADULTHUMANSAREINFECTEDWITH("6 LESSTHANBECOMECHRON ICCARRIERS; =("6INFECTIONEARLYINLIFE HOWEVER RESULTSINCHARACTER ISTICALLYHIGHRATESOFCHRONICINFECTION; =(IGHRATESOFCHRONIC7(6 INFECTIONHAVEBEENOBSERVEDINWOODCHUCKSFROMHYPERENDEMICAREAS;  =ANDSUGGESTEDTHAT ASINHUMANS INFECTIONOFWOODCHUCKSEARLYIN LIFEORPOSSIBLYVERTICALTRANSMISSION MUSTBENECESSARYTOACCOUNTFORTHE HIGHRATESOFPERSISTENT7(6INFECTIONOBSERVED 4OFULLYUTILIZETHEWOODCHUCKASANEXPERIMENTALANIMALMODEL ITWAS CONSIDEREDESSENTIALTOBREEDANDTOREARWOODCHUCKSINALABORATORYANI MALFACILITY4HISWOULDPROVIDEWOODCHUCKSOFKNOWNGENETICBACKGROUND ADEFINEDENVIRONMENTALANDNUTRITIONALHISTORY ANDINWHICHTHEDISEASES OF WILD WOODCHUCKS INCLUDING 7(6 INFECTION COULD BE CONTROLLED AND PREVENTED!BREEDINGCOLONYOFWOODCHUCKSTHATWERENEGATIVEFORSERO LOGIC MARKERS OF7(6 INFECTION WAS ESTABLISHED AT #ORNELL 5NIVERSITY IN 4HECOLONYHASSERVEDASTHESOURCEOFWOODCHUCKSFOREXPERIMENTAL STUDIES OF THE PATHOGENESIS OF 7(6 INFECTION AND HEPATOCARCINOGENESIS AND MORE RECENTLY FOR THE PRECLINICAL DEVELOPMENT OF ANTIVIRAL DRUGS AND IMMUNOTHERAPEUTIC STRATEGIES FOR ("6 INFECTION 7OODCHUCKS BORN IN THE LABORATORY ARE INOCULATED AT BIRTH WITH DILUTED SERUM FROM STANDARD IZED INFECTIOUS POOLS OBTAINED FROM CHRONIC7(6 CARRIERS ;n=!FTER INOCULATION WOODCHUCKS ARE MONITORED USING SPECIFIC SEROLOGICAL MARKERS OF7(6INFECTION7(6$.! 7(S!G ANTI 7(COREANTIBODY ANDANTI 7(SURFACEANTIBODY ; =



"UD#4ENNANTETAL

4HERATEOFCHRONIC7(6INFECTIONAFTERNEONATALINOCULATIONISOR GREATER;n=3URVIVALOFEXPERIMENTALLYINFECTEDCHRONIC7(6CARRIERS WASCOMPAREDTOTHATOFWOODCHUCKSTHATRECOVEREDFROMNEONATAL7(6 INFECTIONBYCLEARING7(VIREMIAANDDEVELOPINGANTI 7(SANTIBODY ANDOF CONTROLWOODCHUCKSNOTINFECTEDWITH7(6BUTTHATWEREBORNANDREARED IN A SIMILARLY CONTROLLED LABORATORY ENVIRONMENT!LL7(6 CARRIERS WERE DEADBYMONTHSOFAGE ANDTHELIFETIMERISKOF(##WAS;  =4HE MEDIAN TIME TO DEATH FROM (## IN7(6 CARRIERS WAS APPROXI MATELYMONTHS)NCONTRAST OFTHEWOODCHUCKSWITHRESOLVED7(6 INFECTION AND  OF UNINFECTED CONTROLS WERE ALIVE AT  MONTHS OF AGE !LTHOUGHTHERATEOF(##IN7(6CARRIERSWASSIGNIFICANTLYHIGHER OF WOODCHUCKSTHATRECOVEREDFROMNEONATAL7(6INFECTIONDEVELOPED(## ; = (## WAS NOT OBSERVED IN UNINFECTED LABORATORY REARED CONTROL WOODCHUCKS (## ASSOCIATED WITH EXPERIMENTAL7(6 INFECTION WAS COMPARABLE TO THAT OF WOODCHUCKS WITH NATURALLY ACQUIRED CHRONIC 7(6 INFECTION ;  =4HE PRESENCE OF PRENEOPLASTIC FOCI OF ALTERED HEPATOCYTES ; = AND PROGRESSIVE ANEUPLOID CHANGE ; = ALSO WAS SIMILAR4HESE RESULTS PROVIDEDIRECTEXPERIMENTALEVIDENCEFORTHECARCINOGENICITYOF7(6AND BYANALOGY FORTHATOFOTHERMAMMALIANHEPADNAVIRUSES("6 '3(6 AND !'3(6 IN WHICH NATURALLY ACQUIRED INFECTION HAS BEEN ASSOCIATED WITH (## 4HEPREVALENCEOF(##INHUMANSISHIGHERINMENTHANINWOMEN)N !SIA WHERE("6INFECTIONISHYPERENDEMIC THERATIOMAYBEASHIGHASOR 4HEEXPLANATIONFORTHEDIFFERENCEISNOTFULLYUNDERSTOODBUTMENHAVE HIGHERRATESOF("6INFECTION ANDAREKNOWNTOHAVEGREATERUSEOFALCOHOL AND TOBACCO THAN WOMEN ; = )N EXPERIMENTAL RODENT MODELS HIGHER RATESOF(##ALSOARECONSISTENTLYOBSERVEDINMALES(ORMONALFACTORSARE CRITICALINDETERMININGTHEMALEPREDILECTIONTODIETHYLNITROSAMINE$%. INDUCED (## BECAUSE CASTRATION OR ADMINISTRATION OF ESTROGEN TO MALE MICEDIMINISHESTHEDEVELOPMENTOF(##SIGNIFICANTLY;=2ECENTSTUDIES OF+ARINANDHISASSOCIATESHAVEEXTENDEDOURUNDERSTANDINGOFTHEGENETIC ANDHORMONALFACTORSTHATAREIMPORTANTINHEPATOCARCINOGENESISANDHAVE DELINEATEDTHEMOLECULARMECHANISMRESPONSIBLEFORTHEPROPHYLACTICBEN EFITOFESTROGEN;=4HEYOBSERVEDTHAT$%.ADMINISTRATIONCAUSEDGREATER INCREASESINTHESERUMCONCENTRATIONOFINTERLEUKIN ),  INMALESTHAN INFEMALESANDABLATIONOFTHE), GENEELIMINATEDTHEDIFFERENCESBETWEEN GENDERS IN HEPATOCARCINOGENESIS $%. EXPOSURE PROMOTED PRODUCTION OF ),  IN +UPFFER CELLS VIA THE 4OLL LIKE RECEPTOR ADAPTOR PROTEIN -Y$ AND ABLATION OF -Y$ PROTECTED MALE MICE AGAINST $%. INDUCED (## %STROGEN REDUCED PLASMA ),  IN $%. TREATED MALE MICE AND INHIBITED PRODUCTIONOF), BY+UPFFERCELLS SUGGESTINGTHATREDUCED), PRODUCTION BY+UPFFERCELLSWASCRITICALINREDUCINGTHERISKOF(##INFEMALES4HESE

4HEWOODCHUCKMODELOFHEPADNAVIRUSINFECTION



AUTHORSSUGGESTEDTHEIRFINDINGSMIGHTBETRANSLATEDFORUSEINTHEPREVEN TIONOF(##INHIGHRISKINDIVIDUALSPRESUMABLYINCOMBINATIONWITHOTHER STRATEGIESSUCHASANTIVIRALDRUGTHERAPYTOINHIBITVIRALREPLICATION PREVENT CHRONICHEPATITISANDDECREASETHERISKOFCIRRHOSIS )N WOODCHUCKS GENDER DOES NOT INFLUENCE EITHER THE RATE OF CHRONIC 7(6 INFECTION OR THE OCCURRENCE OF (## IN CHRONIC7(6 CARRIERS4HIS RESULTWASUNEXPECTEDBECAUSEOFTHEEXPERIENCEINHUMANSINFECTEDWITH ("6ANDINLABORATORYRODENTSJUSTDESCRIBED4HEEXPLANATIONMAYRELATE TOTHEUNUSUALCIRCANNUALREPRODUCTIVECYCLEOFTHEWOODCHUCK&ORATLEAST MONTHSOFTHEYEAR THETESTICLESOFMALEWOODCHUCKSAREABDOMINALAND PRODUCELITTLEORNOTESTOSTERONERESULTINGINFUNCTIONALCASTRATION;= )MMUNE MEDIATEDGLOMERULONEPHRITISHASBEENREPORTEDINWOODCHUCKS WITHEXPERIMENTALLYINDUCEDCHRONIC7(6INFECTION!FFECTEDWOODCHUCKS MAY DEVELOP SEVERE PROTEIN LOSING NEPHROPATHY AND SIGNS SIMILAR TO THE NEPHROTIC SYNDROME OF HUMANS 3UCH WOODCHUCKS DEVELOP HYPOALBUMIN EMIA AND GENERALITIC PERIPHERAL EDEMA4HIS IS THE ONLY DISEASE OF WOOD CHUCKSCAUSEDBY7(6THATOCCURSOUTSIDETHELIVER;= &ULL LENGTH CLONES OF THE GENOMES OF ("6 ;= 7(6 ;= $("6 ;= AND '3(6 ;= HAVE BEEN SHOWN TO PRODUCE PRODUCTIVE INFECTION BY DIRECT INJECTION OF PLASMID $.! INTO THE HEPATIC PARENCHYMA OF THE RESPECTIVE HOST SPECIES $URING TRANSFECTION EXPERIMENTS WITH CHIMERAS OF '3(67(6 GENOMES TO DETERMINE THE VIRAL GENE OR GENES RESPONSIBLE FORRESTRICTIONOFHOSTRANGE ITWASDISCOVEREDTHATWOODCHUCKSWEREFULLY SUSCEPTIBLETOINFECTIONWITH'3(6;='3(6HADBEENSHOWNEARLIERTO INFECTTHECHIPMUNK%UTAMIASSPECIES ;=!SDESCRIBEDABOVE #ALIFORNIA GROUNDSQUIRRELSTHATARECHRONICALLYINFECTEDWITH'3(6DEVELOP(##LESS FREQUENTLYTHANWOODCHUCKSCHRONICALLYINFECTEDWITH7(6; n=AND (##DEVELOPSIN#ALIFORNIAGROUNDSQUIRRELSATANOLDERAGE;="ECAUSE WOODCHUCKSCOULDBEINFECTEDWITHBOTH7(6AND'3(6 ITWASPOSSIBLETO DETERMINEIFTHEAPPARENTDIFFERENCEINONCOGENICITYOF'3(6AND7(6IN THEIRRESPECTIVENATURALHOSTSWASTHERESULTOFDIFFERENCESINHOSTRESPONSE ORWERERELATEDTODIFFERENCESINVIRALGENETICS 7HEN NEONATAL WOODCHUCKS WERE EXPERIMENTALLY INFECTED EITHER WITH 7(6 OR '3(6 THE RATES OF CHRONIC INFECTION WERE SIMILAR ;= "Y  YEARS OF AGE HOWEVER HEPATIC NEOPLASMS OF VARIOUS SIZES WERE OBSERVED ATLAPAROTOMYINOFCHRONIC7(6CARRIERS!TTHESAMEAGE ONLYONE OFCHRONIC'3(6CARRIERSHADDEVELOPEDAGROSSLYIDENTIFIABLEHEPATIC NEOPLASM A  MM DIAMETER NODULE CLASSIFIED HISTOLOGICALLY AS A HEPATIC ADENOMA )T WAS CONCLUDED BASED ON THESE OBSERVATIONS THAT THE DIFFER ENCES IN ONCOGENIC CAPACITY OF '3(6 AND7(6 THAT WERE RECOGNIZED IN THEIRRESPECTIVENATURALHOSTSPECIESWEREATTRIBUTABLETOVIRALGENETICDIF FERENCESBETWEENTHEVIRUSES ALTHOUGHDIFFERENCESINHOSTRESPONSESCOULD NOTBEEXCLUDED



"UD#4ENNANTETAL

(EPATOCARCINOGENESISASSOCIATEDWITHHEPADNAVIRUSINFECTION 4HREE CATEGORIES OF EVIDENCE INDICATE THAT ("6 IS AN ETIOLOGIC FACTOR IN HEPATOCARCINOGENESIS &IRST SEROEPIDEMIOLOGIC EVIDENCE HAS DEMONSTRATED A CLOSE RELATION BETWEEN THE PREVALENCE OF INFECTION WITH ("6 AND THE OCCURRENCEOF(##; =3IGNIFICANTLYHIGHERRATESOF(##AREOBSERVED ININDIVIDUALSWITHCHRONIC("6INFECTIONTHANINCASECONTROLSINTHEHYPER ENDEMIC REGIONS OF!FRICA ;n= AND!SIA ;n= )N THE 5NITED 3TATES AND'REAT"RITAINWHERETHERATESOF("6INFECTIONAND(##ARERELATIVELY LOW ASIMILARRELATIONSHIPBETWEEN("6INFECTIONAND(##WASOBSERVED ;n=#OMPELLINGEPIDEMIOLOGICEVIDENCEFORTHEROLEOF("6INHEPA TOCARCINOGENESIS COMES FROM THE EPIDEMIOLOGICAL STUDIES OF "EASLEY AND COLLEAGUES IN 4AIWAN WHO PROSPECTIVELY DEMONSTRATED THAT CHRONIC ("6 CARRIERSHADEXTRAORDINARILYHIGHRELATIVERISKOFDEVELOPING(##COMPARED TONON CARRIERS;n=!SIMILARHIGHRELATIVERISKOF(##IN("6CARRIERS ISOBSERVEDINTHE5NITED3TATES;= 4HE SECOND FORM OF EVIDENCE SUGGESTING AN ETIOLOGIC ROLE OF HEPADNA VIRUSESINHEPATOCARCINOGENESISISMOLECULAR#OVALENTINTEGRATIONOFTRUN CATED("6$.!SEQUENCESINTHECELLULAR$.!OFHEPATICTUMORSOFMOST ("6CARRIERS;n=SUGGESTSTHAT("6HASADIRECTROLEINHEPATOCARCINO GENESISSIMILARTOTHATOFOTHERTUMOR PRODUCINGVIRUSESINWHICHINTEGRATED VIRAL $.! OR PROVIRAL $.! IN THE CASE OF RETROVIRUSES CAUSES NEOPLASTIC CELLTRANSFORMATIONBYINSERTIONALMUTAGENESIS; =&INALLY ATLEASTFOUR MEMBERS OF THE FAMILY 3CIURIDAE HAVE BEEN DESCRIBED IN WHICH PERSISTENT HEPADNAVIRUSINFECTIONISCLOSELYASSOCIATEDWITHTHEDEVELOPMENTOF(## ;= AND THIS OBSERVATION COMBINED WITH THE EXPERIMENTAL INDUCTION OF (##INLABORATORYWOODCHUCKSINFECTEDATBIRTHWITH7(6;=PROVIDES CREDIBLECOMPARATIVEMEDICALEVIDENCEFORTHEETIOLOGICROLEOFHEPADNAVI RUSESINHEPATOCARCINOGENESIS;=

-OLECULARMECHANISMSOFHEPATOCARCINOGENESISASSOCIATEDWITH HEPADNAVIRUSINFECTION 4HE SPECIFIC MECHANISMS BY WHICH HEPADNAVIRUSES CAUSE (## ARE NOT COMPLETELY UNDERSTOOD BUT TWO GENERAL MECHANISMS HAVE BEEN PROPOSED )N THE DIRECT MOLECULAR MODEL ;n= INTEGRATION OF HEPADNAVIRAL $.! INTOHOSTCELL$.!RESULTSININSERTIONALMUTATIONS ANDALTEREDEXPRESSION OFAGENEORGENESTHATREGULATETHECELLCYCLEPROTOONCOGENESANDTUMOR SUPPRESSORGENES )NTHISMODEL NEOPLASTICTRANSFORMATIONOFHEPATOCYTES ISINITIATEDBYINTEGRATIONOFHEPADNAVIRAL$.!INAMANNERANALOGOUSTO THATOFCHEMICALHEPATOCARCINOGENS; = 4HEMOLECULARHYPOTHESISISBASEDONDETECTIONOFHEPADNAVIRALINTEGRA TIONSINTHECELLULAR$.!OFMOST(##SFROMPATIENTSINFECTEDWITH("6 ;n=#HARACTERISTICALLY ONLYPORTIONSOFTHEVIRALGENOMEAREINTEGRATED

4HEWOODCHUCKMODELOFHEPADNAVIRUSINFECTION



AND SEQUENCES OFTEN ARE REARRANGED ; = )N STUDIES OF THE FLANKING SEQUENCES ("6INTEGRANTSHAVEBEENDETECTEDINFREQUENTLYNEARAKNOWN PROTOONCOGENE OR TUMOR SUPPRESSOR GENE AND AS A CONSEQUENCE INTEGRA TIONSWERECONSIDEREDTOHAVEBEENRANDOMWITHINTHEGENOME-ORERECENT STUDIES OF HUMAN (##S HAVE DEMONSTRATED RECURRENT PATTERNS OF ("6 INTEGRATION INVOLVING MULTIPLE GENE FAMILIES AND THE TELOMERASE REVERSE TRANSCRIPTASE; =)NTHESTUDYOFHUMAN(##SBY0ATERLINI "RECHOTAND HER COLLEAGUES INTEGRANTS WERE FOUND IN ALL CHROMOSOMES WITH THE EXCEP TIONOF 8 AND9;= )NTHE(##SOFMOST7(6CARRIERS INTEGRATED7(6$.!SEQUENCES HAVEBEENDEMONSTRATED;n=-OLECULARCLONINGANDANALYSESOFINTE GRATED7(6$.!ANDOFFLANKINGCELLULAR$.!SEQUENCESINDICATEDTHAT INTEGRATIONS OCCURRED AT MULTIPLE SITES WITHIN THE WOODCHUCK GENOME ;  =-ULTIPLEINTEGRATIONSINASINGLETUMORCOULDBEEXPLAINEDINDIF FERENTWAYS4HEACCUMULATIONOFMULTIPLEINTEGRATIONSINASINGLEHEPATO CYTECOULDOCCURPRIORTOCLONALPROPAGATIONOFTHETRANSFORMEDHEPATOCYTE OR AN INITIAL SINGLE INTEGRATION OF HEPADNAVIRAL $.! COULD BE FOLLOWED BY SECONDARY REARRANGEMENTS OF INTEGRATED VIRAL SEQUENCES DURING TUMOR GROWTH;=!THIRDALTERNATIVECOULDBETHATTWOORMORETUMORSCOULD DEVELOPINDEPENDENTLY FUSEDURINGGROWTH ANDTHENBEREMOVEDANDANA LYZEDASASINGLETUMOR 6IRAL INTEGRATIONS IN THE NON TUMOROUS HEPATIC TISSUE OF ("6 CARRIERS INDICATESTHATINTEGRATIONPRECEDESTHEDEVELOPMENTOFHEPATICNEOPLASMS 5SING3OUTHERNBLOTANALYSIS "RECHOTETALSTUDIEDTHESTATEOF("6$.! IN THE NON NEOPLASTIC LIVER OF GROUPS OF PATIENTS WITH (## WITH CHRONIC HEPATITIS AND WITH ACUTE HEPATITIS ;= )NTEGRATION OF ("6 $.! WAS DETECTEDBOTHINTHECELLULAR$.!OF(##SANDINNON NEOPLASTICHEPATIC TISSUEANDTHEINTEGRATIONPATTERNSWEREDIFFERENT)NTEGRATIONOF("6$.! ALSOWASDEMONSTRATEDINSOMEPATIENTSWITHCHRONICHEPATITISBUTWITHOUT TUMOR INDICATINGTHATINTEGRATIONMAYBEREQUIREDFORHEPATOCYTETRANSFOR MATIONBUTISNOTTHEONLYFACTORRESPONSIBLEFORTHEDEVELOPMENTOF(## )NTHELIVERSOFTWOPATIENTSWITHACUTE("6INFECTION RESTRICTIONANALYSIS SUGGESTEDTHEPRESENCEOFINTEGRATED("6$.!INDICATINGTHATVIRAL$.! INTEGRATIONOCCURSVERYEARLYIN("6INFECTION )NTEGRATIONSOF7(6$.!SEQUENCESHAVEBEENREPORTEDINTHENON NEOPLASTICLIVEROF7(6INFECTEDWOODCHUCKS;  =SUPPORTINGTHE VIEW THAT INTEGRATIONS OF VIRAL $.! OCCUR EARLY IN HEPATOCARCINOGENESIS 7(6$.!INTEGRATIONSALSOHAVEBEENDESCRIBEDINSMALLNEOPLASTICNOD ULES BEFORE DEVELOPMENT OF FRANK (## ;n= 3UMMERS -ASON AND THEIRCOLLEAGUESHAVEELEGANTLYDETERMINEDTHEFREQUENCYOFHEPADNAVIRAL $.! INTEGRATIONS IN INDIVIDUAL HEPATOCYTES IN EXPERIMENTAL ACUTE AND CHRONIC7(6INFECTIONANDINCHRONIC7(6CARRIERSAFTERSUSTAINEDANTIVI RALDRUGTHERAPY;n=)NEXPERIMENTAL$("6INFECTION THELIVERWAS FOUNDTOCONTAINONE$("6$.!INTEGRANTPER TO LIVERCELLS AND SEQUENCE ANALYSIS SUGGESTED THAT LINEAR $("! WAS THE PREDOMINANT



"UD#4ENNANTETAL

SUBSTRATE FOR INTEGRATION ;=! SIMILAR ASSAY SYSTEM AND SIMILAR RESULTS WEREOBTAINEDININVESTIGATIONSOFEXPERIMENTAL7(6INFECTION&OLLOWING RESOLUTION OF ACUTE INFECTION ONE 7(6 $.! INTEGRANT WAS FOUND PER  TO LIVERCELLS;=)NCHRONIC7(6INFECTION ITWASESTIMATED THAT n OF THE TOTAL NON NEOPLASTIC LIVER CELLS CONTAINED SEQUENCES OF INTEGRATED 7(6 $.! ;= 4HE FREQUENCY OF INTEGRATED VIRAL $.! IN CHRONIC7(6CARRIERSWASFOUNDTOBETOORDERSOFMAGNITUDEGREATER THANTHATOBSERVEDINTRANSIENT7(6INFECTION SUGGESTINGTHATINTEGRATIONS ANDOTHERGENOMICALTERATIONSWEREACCUMULATEDOVERTHEDURATIONOFINFEC TION;=7HENCHRONIC7(6CARRIERSRECEIVEDSUSTAINEDTREATMENTWITH THE POTENT NUCLEOSIDE ANALOG CLEVUDINE , &-!5 7(6 CCC$.! WAS DECREASED BY  TO  FOLD BUT NO DETECTABLE DECREASE IN THE FREQUENCY OF7(6INTEGRANTSWASOBSERVED4HISSUGGESTSTHEINTEGRATED7(6$.! SEQUENCESPERSISTEDFOLLOWINGSUBSTANTIALCLEARANCEOFVIRUS ANOBSERVATION THE AUTHORS BELIEVED ARGUED FOR EARLY THERAPEUTIC INTERVENTION IN CHRONIC ("6INFECTION;= (EPADNAVIRUSES DO NOT CONTAIN ONCOGENES SIMILAR TO THOSE FOUND IN TRANSFORMINGRETROVIRUSES; =5PREGULATIONOFMANYOFTHEWELL CHARAC TERIZEDPROTOONCOGENESHASNOTBEENDEMONSTRATED;=)NCREASEDEXPRES SION TO FOLD OFC MYC HOWEVER WASOBSERVED INTHREEOFNINEWOOD CHUCK(##S;n=ANDTRUNCATIONANDREARRANGEMENTOFTHEGENEWERE DEMONSTRATED )N ONE TUMOR THERE WAS NO DIRECT LINKAGE BETWEEN 7(6 $.!INTEGRATIONANDC MYCACTIVATION!CTIVATIONOFC MYCAPPEAREDTOBE COMPARABLETOTHATIN"URKITTSLYMPHOMAANDINACUTE" AND4 CELLLEUKE MIASTHATAREASSOCIATEDWITHCHROMOSOMALTRANSLOCATIONS;=!CTIVATION IN THE OTHER TWO TUMORS WAS RELATED TO INSERTIONAL MUTATIONS ;= WITH 7(6 $.! INSERTIONS INTERRUPTING THE C MYC LOCUS4HE POSITION AND ORI ENTATIONOFTHE7(6INTEGRANTSINRELATIONTOC MYCEXCLUDEDINVOLVEMENT OFTHEHEPADNAVIRALPROMOTERINC MYCACTIVATIONIE PROMOTERINSERTION  7(6SEQUENCESANALOGOUSTOONEOFTHE("6ENHANCERSWEREPRESENTIN THEVIRALINTEGRANTS SUGGESTINGTHEPOSSIBILITYOFENHANCERINSERTION;=)N ALARGESERIESOFWOODCHUCK(##S ACTIVATIONOFC MYCWASOBSERVEDIN OFTHETUMORS;= 4HE EXPRESSION OF . MYC HAS BEEN SHOWN TO BE INCREASED IN  OF WOODCHUCK(##S ANDTHISTRANSCRIPTISNOTDETECTEDINNORMALWOODCHUCK LIVER4WO. MYCLOCIHAVEBEENIDENTIFIEDINWOODCHUCKS/NEISHOMOLO GOUSTOTHE. MYCGENEOFOTHERMAMMALIANSPECIES4HEOTHER IDENTIFIED AS . MYC IS AN INTRONLESS GENE WITH THE CHARACTERISTIC STRUCTURE OF A RET ROTRANSPOSON ;= AND . MYC HAS BEEN MAPPED TO THE 8 CHROMOSOME %XPRESSIONOF. MYCISHIGHLYRESTRICTED ANDTHEBRAINISTHEONLYNORMAL TISSUEOFTHEWOODCHUCKINWHICH. MYC2.!WASDETECTED;= 4HE PHYSIOLOGICAL FUNCTION OF . MYC IF ANY REMAINS UNKNOWN ;= (EPATOCARCINOGENESISINWOODCHUCKSWITHCHRONIC7(6INFECTIONAPPEARS TOBEPREFERENTIALLYASSOCIATEDWITHALTERATIONINEXPRESSIONOFTHE. MYC LOCUS; =)NSERTIONOF7(6ENHANCERSEQUENCESUPSTREAMORDOWN

4HEWOODCHUCKMODELOFHEPADNAVIRUSINFECTION



STREAMOF. MYCWASASSOCIATEDWITHINCREASEDTRANSCRIPTIONOFNORMAL. MYC2.!OROFAHYBRID. MYC7(6TRANSCRIPTINITIATEDATTHE. MYC START SITE %NHANCER INSERTION APPEARS TO BE A COMMON MECHANISM ;= FORINCREASED. MYCEXPRESSION!LIVER SPECIFICREGULATORYELEMENTINTHE 7(6GENOMEHASBEENIDENTIFIEDTHATAPPEARSTOCONTROLCISACTIVATIONOF . MYC;=$OWNSTREAMINTEGRATIONOF7(6$.!ALSOHASBEENASSOCI ATEDWITHACTIVATIONOF. MYC;= 2APICETTA AND HER COLLEAGUES HAVE ANALYZED THE (##S OF WOODCHUCKS TRAPPEDINTHEIRNATIVEHABITATWITHNATURALLYACQUIRED CHRONIC7(6INFEC TION ;= #OMPARISON OF THEIR RESULTS WITH DATA FROM PREVIOUS STUDIES OF WOODCHUCKS WITH EXPERIMENTAL 7(6 DEMONSTRATED THAT TUMORS FROM NATURALLY INFECTED WOODCHUCKS HAD 7(6 INTEGRATIONS NEAR . MYC LESS FREQUENTLY THAN TUMORS FROM EXPERIMENTALLY INFECTED CHRONIC 7(6 CAR RIERS AND . MYC ACTIVATION ASSOCIATED WITH 7(6 INTEGRATIONS NEAR THE . MYCGENEALSOOCCURREDLESSFREQUENTLY VERSUS  0 4HEIR FINDINGS WERE BELIEVED TO BE RELATED TO THE LESS UNIFORM INFECTINGVIRUSANDHOSTGENETICBACKGROUNDOFTHENATURALLYINFECTEDWOOD CHUCKSANDSUGGESTEDTHATVIRALANDORHOSTFACTORSCOULDINFLUENCETHESITE OFVIRALINSERTIONTHATWASDETECTEDFINALLYINHEPATICTUMORS -ORE THAN ONE THIRD   OF THE TUMORS THEY EXAMINED WITH INCREASED. MYCEXPRESSIONSHOWEDNOEVIDENCEOFREARRANGEMENTEITHER NEAR . MYC OR DOWNSTREAM IN EITHER THE WIN OR BN LOCI4HESE FINDINGS INDICATEDTHATNOTALLTUMORSWITHINCREASED. MYCEXPRESSIONWERERELATED TO BN OR WIN INTEGRATIONS AND THE AUTHORS SUGGESTED THAT ACTIVATION OF . MYCINSUCHCASESWASTHERESULTOFCHROMOSOMALINTEGRATIONOF7(6 $.! FURTHER DOWN STREAM OR TO MECHANISMS UNRELATED TO VIRAL INSERTION ;= *ACOBETALEXAMINEDTHEFREQUENCYOF$.!INTEGRATIONSANDREARRANGE MENTSOFTHE. MYCGENEINHEPATICTUMORSFROMWOODCHUCKSWITH (## AND COMPARED THE RESULTS OF THE MOLECULAR CHANGES TO THE SIZE AND HISTOLOGICAL CHARACTERISTICS OF THE HEPATIC TUMORS ;= &OUR SMALL TUMOR NODULESWERECLASSIFIEDHISTOLOGICALLYASADENOMASANDINTEGRATEDSEQUENC ES OF7(6 $.! WERE DETECTED IN TWO OF THE FOUR TUMOR NODULES AND IN ONEOFTHETWO THEREWASEVIDENCEOF. MYCREARRANGEMENTNEOPLASMS WERE CLASSIFIED AS (## 3EVEN WERE CLASSIFIED WELL DIFFERENTIATED GRADE  (##S7(6$.!INTEGRATIONSWEREDEMONSTRATEDINBUTNONEHAD DETECTABLE . MYC REARRANGEMENTS  GRADE  MODERATELY WELL DIFFERENTI ATED (##S WERE ANALYZED AND7(6 $.! INTEGRATIONS WERE DETECTED IN AND. MYCREARRANGEMENTSWEREPRESENTINPOORLYDIFFERENTI ATED GRADE(##SHAD7(6INTEGRATIONSINAND. MYCREARRANGE MENTSWEREDETECTEDIN)NTWOOTHERGRADE(##S REARRANGEMENTS OF . MYC WERE DETECTED IN THE ABSENCE OF 7(6 $.! INTEGRATIONS 4HE LARGESTTUMORSINTHESERIESWERECLASSIFIEDASEITHERGRADEORGRADE (##S ANDINOFTHELARGESTTUMORS BOTH7(6$.!INTEGRATIONSAND . MYC REARRANGEMENTS WERE DEMONSTRABLE! SERIES OF GENETIC ALTERATIONS



"UD#4ENNANTETAL

WEREDEMONSTRATEDINWOODCHUCK(##STHATWEREDIRECTLYRELATEDTOTUMOR SIZEANDTHEDEGREEOFHISTOLOGICALDIFFERENTIATIONANDAPPEAREDTOPROVIDE PROGRESSIVEPROLIFERATIVESTIMULUSANDORGROWTHADVANTAGE;= "UENDIA AND HER COLLEAGUES HAVE REPORTED THAT TRANSGENIC MICE CARRY INGTHE. MYCGENEUNDERTHECONTROLOF7(6REGULATORYSEQUENCESARE HIGHLYPREDISPOSEDTOCANCEROFTHELIVER;=DEVELOPEDEITHER(## ORHEPATOCELLULARADENOMAS!TRANSGENICFOUNDERTHATCARRIEDTHEUNMETH YLATED 7(6. MYC TRANSGENE SEQUENCE DIED AT THE AGE OF  MONTHS WITHALARGELIVERTUMOR DEMONSTRATINGTHEHIGHONCOGENICCAPACITYOFTHE WOODCHUCK. MYCRETROPOSON-UTATIONSORDELETIONSOFTHE` CATENINGENE SIMILARTOTHOSEOF(##SFROMHUMANSANDMICE;=WEREPRESENTIN OFTHEHEPATICTUMORSOFTHE. MYCTRANSGENICANIMALS ANDTUMORLATENCY TIME TO TUMOR WAS SIGNIFICANTLY REDUCED ;=7HEN . MYC TRANSGENIC MICEWERECROSSEDWITHPNULLMICE THEABSENCEOFONEPALLELEMARK EDLY ACCELERATED THE ONSET OF LIVER CANCER PROVIDING DIRECT EXPERIMENTAL EVIDENCEFORSYNERGYINMULTISTAGEHEPATOCARCINOGENESISBETWEENACTIVATION OF. MYCANDDIMINISHEDEXPRESSIONOFP;= ,IKE THE WOODCHUCK THE #ALIFORNIA GROUND SQUIRREL POSSESSES A FUNC TIONAL TRANSCRIPTIONALLY ACTIVE . MYC LOCUS IN THE BRAIN ;= (OWEVER INCREASED . MYC EXPRESSION IS UNUSUAL IN (##S FROM #ALIFORNIA GROUND SQUIRRELSINFECTEDWITH'3(6!MPLIFICATIONOF# MYCEXPRESSION HOWEVER IS MORE FREQUENT IN GROUND SQUIRREL HEPATIC NEOPLASMS THAN IN THOSE OF WOODCHUCKS;=(##SFROMWOODCHUCKSEXPERIMENTALLYINFECTEDEITHER WITH7(6 OR WITH '3(6 HAVE BEEN ANALYZED ;=4HE PROPENSITY FOR 7(6GENOMIC$.!TOINTEGRATEINORNEARTHE. MYCLOCUSIN(##SFROM CHRONIC7(6CARRIERSWASCONFIRMED WHEREASINWOODCHUCK(##SASSOCI ATED WITH '3(6 INFECTION SUCH INTEGRATIONS WERE EXCEPTIONAL 3EVEN OF  7(6 INDUCEDTUMORSHADREARRANGEMENTSOFTHE. MYCALLELE /NLYONEOF'3(6 ASSOCIATEDTUMORS HOWEVER HADSUCH. MYC REARRANGEMENTS"ASEDONTHEOBSERVATIONSIN'3(6 INDUCED(##SFROM GROUNDSQUIRRELSANDFROMWOODCHUCKS ITWASCONCLUDEDTHATTHEDIFFERENC ESINHEPADNAVIRUSINSERTIONANDIN. MYCACTIVATIONBETWEENWOODCHUCKS ANDGROUNDSQUIRRELSWEREDUEPRIMARILYTOVIRALGENETICDIFFERENCESANDNOT TODIFFERENCESINTHERESPECTIVEHOSTSPECIES;=!SIMILARCONCLUSIONWAS REACHEDBY"UENDIAANDHERCOLLEAGUES;= 4RANSFECTION OF A NONMALIGNANT 36  4 ANTIGEN TRANSFORMED MOUSE HEPATICCELLLINEWITH("6$.!PRODUCEDCELLSWITHAMALIGNANTPHENOTYPE THATGREWINSOFTAGARANDWERETUMORIGENICINNUDEMICE("8TRANSCRIPT WAS EXPRESSED AT A MUCH HIGHER LEVEL THAN THAT OBSERVED IN VIVO ;= )N SUBSEQUENTSTUDIES ITWASCONCLUDEDTHATOVER EXPRESSIONOFTHE("8WAS REQUIREDFORMALIGNANTTRANSFORMATIONOFTHECELLLINE;=("8ISKNOWN TO PROMOTE HEPATOCARCINOGENESIS IN C MYC TRANSGENIC MICE ;= AND MAY PROMOTEHEPADNAVIRUS INDUCEDHEPATOCARCINOGENESIS;= 4HE8GENEAPPEARSTOBEESSENTIALFORNORMALREPLICATIONOFHEPADNA VIRUSESINVIVO4HE7(8PROTEINISCOEXPRESSEDWITH7(C!GINTHELIVER

4HEWOODCHUCKMODELOFHEPADNAVIRUSINFECTION



OF CHRONIC 7(6 CARRIER WOODCHUCKS ; = &EITELSON DEMONSTRATED THATWHEN7(8WASCO TRANSLATEDINVITROWITHP 7(8PCOMPLEXES DEVELOPED ANDSIMILAR7(8PCOMPLEXESWEREDEMONSTRATEDINTHELIV ERS OF CHRONIC7(6 CARRIERS ;= #OMBINED WITH OBSERVATIONS IN ("6 TRANSGENICMICE; = THEOBSERVATIONSOF&EITELSONETALSUGGESTTHAT BINDINGOF7(8TOPMAYPREVENTENTRYOFPINTOTHENUCLEUS DIMIN ISH TUMOR SUPPRESSOR ACTIVITY AND REPRESENT AN IMPORTANT MECHANISM BY WHICHTHEHEPADNAVIRUS8 GENEPRODUCTCOULDPROMOTEHEPATOCARCINOGEN ESIS ;= -UTATIONS OF P ALSO MAY ALTER ITS TUMOR SUPPRESSOR ACTIVITY BUTSUCHMUTATIONSWEREFOUNDPRIMARILYINTHELESSDIFFERENTIATEDHEPATIC TUMORS SUGGESTINGTHEMUTATIONSALTEREDTUMORPROGRESSIONATALATERSTAGE OFDEVELOPMENT; =

)NFLAMMATIONANDHEPATOCYTEREGENERATIONINHEPADNAVIRUS ASSOCIATEDHEPATOCARCINOGENESIS )NFLAMMATION ASSOCIATED INFECTIONS ARE RECOGNIZED AS IMPORTANT RISK FAC TORS FOR CANCER (EPATITIS ASSOCIATED WITH CHRONIC ("6 INFECTION IS A WELL RECOGNIZEDEXAMPLEBUTHOWINFLAMMATION OFTHELIVERINFLUENCESHEPATO CARCINOGENESISISNOTFULLYUNDERSTOOD.& g"CANPROMOTEORINHIBITCARCI NOGENESIS.& g"PRODUCEDBYINFLAMMATORYCELLSINRESPONSETOINFECTIOUS AGENTS TONECROTICCELLSORTOCYTOKINESRESULTSINTHEPRODUCTIONOFSOLUBLE FACTORSTHATENHANCECELLGROWTH SURVIVIALANDVASCULARIZATIONOFCARCINOMA CELLS.& g"PRODUCEDBYCARCINOMACELLSINCREASESTHEPRODUCTIONOFINHIBI TORS OF APOPTOSIS AND OF PROTEASES THAT FACILITATE CELL INVASION 2EVIEWED ; =  (## DEVELOPS REGULARLY IN A SETTING OF CHRONIC HEPATITIS AND EVIDENCE IS ACCUMULATING THAT CHRONIC LIVER INFLAMMATION HAS AN IMPORTANT ROLE IN HEPATOCARCINOGENESIS ;  = 3UPPORT FOR A MODEL IN WHICH INFLAM MATION IS A KEY FACTOR IN HEPATOCARCINOGENESIS COMES FROM THE OBSERVA TIONTHATCHRONICLIVERINJURYASSOCIATEDWITHCIRRHOSISFREQUENTLYPRECEDES THE DEVELOPMENT OF (## IN ("6 INFECTED INDIVIDUALS ; = #HRONIC HEPATITIS # VIRUS INFECTION RESULTS IN SEVERE CHRONIC HEPATITIS AND CIRRHOSIS THATFREQUENTLYLEADSTO(##BUTINTHISFORMOF(## THEREISNOEVIDENCE OFVIRALNUCLEICACIDINTEGRATIONINTOCELLULAR$.!)NCREASEDRATESOF(## INHUMANSAREOBSERVEDININHERITEDFORMSOFCHRONICLIVERDISEASEINCLUD ING HEMOCHROMATOSIS ALPHA  ANTITRYPSIN DEFICIENCY AND7ILSONS DISEASE ;=4HESEDISEASESALSOAREASSOCIATEDWITHDEVELOPMENTOFPROGRESSIVELY SEVEREHEPATOCELLULARINJURY HEPATOCELLULARREGENERATION ANDCIRRHOSISTHAT PRECEDEDEVELOPMENTOF(##;= %XPERIMENTAL SUPPORT FOR THE ROLE OF HEPATIC INFLAMMATION AND HEPA TOCELLULAR INJURY IN HEPATOCARCINOGENESIS COMES FROM STUDIES REPORTED BY #HISARIANDHISCOLLEAGUESUSINGTRANSGENICMICE;n=!DIRECTRELATION WASFOUNDBETWEENTHEEXPRESSIONANDRETENTIONOF("S!GINHEPATOCYTES



"UD#4ENNANTETAL

ANDTHESEVERITYOFHEPATITISANDTHESEVERITYOFHEPATITISWASCORRELATEDWITH THEDEVELOPMENTOF(##;  =)NCREASEDFREERADICALPRODUCTION WITHINTHELIVERWASASSOCIATEDWITHOXIDATIVE$.!DAMAGEINWOODCHUCKS ;=AFINDINGALSOREPORTEDPREVIOUSLYINMICE;= (EPATICINJURYASSOCIATEDWITH7(6INFECTIONINCREASESTHERATEOFHEPA TOCYTEDEATHANDREGENERATIONANDPROVIDESANENVIRONMENTTHATENHANCES FIXATIONOFSPONTANEOUSMUTATIONS REARRANGEMENTS ORCHROMOSOMALTRANS LOCATIONS THAT MAY BE RESPONSIBLE FOR MALIGNANT TRANSFORMATION OF HEPA TOCYTES 3UCH A ROLE FOR HEPADNAVIRUSES IN HEPATOCARCINOGENESIS WOULD BE COMPARABLETOTHEPROCESSESOFPROMOTIONANDORPROGRESSIONRECOGNIZEDIN MULTISTAGECHEMICALHEPATOCARCINOGENESIS;   = !NOTHER POSSIBLE HEPATOCARCINOGENIC MECHANISM RELATED DIRECTLY TO HEPATIC INFLAMMATION HAS BEEN SUGGESTED BY STUDIES OF NITRIC OXIDE ./ PRODUCTION IN CHRONIC VIRAL HEPATITIS )N THE LIVER ./ BIOSYNTHESIS FROM ARGININEISCATALYZEDBYINDUCIBLE./SYNTHETASE%NDOTOXIN a INTERFERON ANDOTHERCYTOKINES;n=CANINCREASETHEACTIVITYOFTHISENZYMESIG NIFICANTLY5NDERSOMECIRCUMSTANCES ./MAYBEPROTECTIVEAGAINSTEXPERI MENTALHEPATICINJURY;=5NDEROTHERCONDITIONS HEPATICPRODUCTIONOF ./MAYCONTRIBUTETODEVELOPMENTOFHYPOTENSIONINSEPTICSHOCK;= 7OODCHUCKSCHRONICALLYINFECTEDWITH7(6EXCRETEMORENITRATEINTHE URINEANDMORE.$-!THANUNINFECTEDCONTROLWOODCHUCKS;=3IMILAR INCREASED ./ PRODUCTION HAS BEEN OBSERVED IN ("6 TRANSGENIC MICE ;=.ITRATEAND.$-!AREDERIVEDFROM./PRODUCEDFROM, ARGININE 5RINARYNITRATEEXCRETIONALSOISINCREASEDINAHUMANPATIENTWITHCHRONIC ("6INFECTION;= )NPRIMARYHEPATOCYTECULTURESFROMNORMALWOODCHUCKS ./SYNTHESIS CANBEINDUCEDBYENDOTOXIN ANDHEPATOCYTESCULTUREDFROMCHRONIC7(6 CARRIERSPRODUCESIGNIFICANTLYMORE./ANDNITROSAMINETHANHEPATOCYTES FROM UNINFECTED CONTROLS ;= 36  4 ANTIGEN TRANSFORMED WOODCHUCK HEPATOCYTECELLLINESHAVETHECAPACITYTOPRODUCE./INRESPONSETOENDO TOXIN ;= UTILIZING THE , ARGININE ./ PATHWAY AND TO PRODUCE .$-! 7(S!G PURIFIED FROM WOODCHUCK SERUM CAN INDUCE ./ PRODUCTION IN WOODCHUCKHEPATOCYTECULTURES;=./REACTSWITH/TOPRODUCE./ WHICHEXISTSINEQUILIBRIUMWITH./AND././OR./AREPOTENT NITROSATINGAGENTSCAPABLEOFREACTINGWITHWATERTOFORMNITRITEANDNITRATE ;= OR IN NEUTRAL SOLUTION OF NITROSATING DIALKYLAMINES TO FORM NITROSA MINES ./ COULD ACT AS A CARCINOGEN INDIRECTLY BY CAUSING FORMATION OF HEPATOCARCINOGENICNITROSAMINESSUCHAS.$-! WHICHISASTRONGALKYLAT ING AGENT 0OINT MUTATIONS CAN BE INDUCED BY .$-! BY METHYLATION OF GUANINETO METHYLANDTO METHYLGUANINE ORBYMETHYLATIONOFADENINE TO METHYLADENINE; = ./ALSOHASTHECAPACITYTOACTASADIRECTMUTAGEN;=)NVITRO ./ CAN DEAMINATE DEOXYNUCLEOSIDES DEOXYNUCLEOTIDES OR INTACT $.! AND CONTRIBUTE TO DEAMINATION RELATED MUTATIONS )T HAS BEEN PREDICTED BASED ON STUDIES OF THE RATE OF DEAMINATION OF GUANINE TO XANTHINE IN VITRO THAT

4HEWOODCHUCKMODELOFHEPADNAVIRUSINFECTION



GUANINECYTOSINEaADENINETHYMINETRANSITIONSCOULDBEAFREQUENTFORMOF MUTATIONINDUCEDBY./!DENOSINEDEAMINATIONTOHYPOXANTHINEWOULD BE EXPECTED TO RESULT IN ADENINETHYMINE TO GUANINECYTOSINE TRANSITIONS ANDREMOVALOFTHEXANTHINEFORMEDBYGUANINEDEAMINATIONWOULDRESULT IN DEPURINATION AND GUANINECYTOSINE TO THYMINEADENINE TRANSVERSIONS ;=4HEDEMONSTRATIONOFINCREASED./FORMATIONINTHEHEPADNAVIRUS INFECTEDLIVERSUGGESTSTHAT./COULDHAVEANIMPORTANTROLEINHEPATOCAR CINOGENESIS

)NTERACTIONOFHEPADNAVIRUSANDOTHERHEPATOCARCINOGENS !FLATOXINISAMONGTHEMOSTPOTENTHEPATOCARCINOGENSKNOWNANDISAFRE QUENTCONTAMINANTOFTHEDIETSOFPOPULATIONSWITHHIGHINCIDENCERATESOF ("6 INFECTION AND (##4HE POSSIBLE INTERACTION BETWEEN HEPADNAVIRUS INFECTION AND AFLATOXIN HAS BEEN INVESTIGATED USING THE WOODCHUCK MODEL ;  =7HENADMINISTEREDEARLYINLIFETOWOODCHUCKSEXPERIMEN TALLYINFECTEDATBIRTHWITH7(6 AFLATOXIN"DIDNOTAPPEARTOINCREASETHE RATE OF CHRONIC7(6 INFECTION OR THE RATE OF DEVELOPMENT OF (## ;= 7HENADMINISTEREDTOESTABLISHEDCHRONIC7(6CARRIERSATONEYEAROFAGE AFLATOXIN"APPEAREDTOPROMOTE(##ANDTHETIMETOTUMORWASMODER ATELY REDUCED ;=! SIMILARLY SYNERGISTIC INTERACTION BETWEEN ("6 AND AFLATOXINHASBEENREPORTEDINTHETREESHREW;= 7HEN TRANSGENIC MICE THAT EXPRESSED ("S!G WERE EXPOSED TO $%. OR AFLATOXIN THEY DEVELOPED HEPATIC ADENOMAS AND (## MORE RAPIDLY AND MORE EXTENSIVELY THAN UNEXPOSED TRANSGENIC CONTROLS OR NORMAL MICE RECEIVING EITHER HEPATOCARCINOGENS4HESE RESULTS DEMONSTRATED A SYNERGY BETWEEN THE CHEMICAL HEPATOCARCINOGENS AND THE CHRONIC HEPATOCELLULAR INJURY CAUSED BY OVEREXPRESSION OF ("S!G IN TRANSGENIC MICE ;= ! SIMILAR SYNERGISTIC EFFECT OF ("8 EXPRESSION IN TRANSGENIC MICE AND $%. ONHEPATOCARCINOGENESISHASALSOBEENREPORTED;=

4HEWOODCHUCKMODELANDANTIVIRALDRUGDEVELOPMENT #HRONIC7(6 CARRIER WOODCHUCKS FREQUENTLY HAVE BEEN USED IN THE PRE CLINICALEVALUATIONOFANTIVIRALDRUGSDURINGDEVELOPMENTFORTHETREATMENT OF CHRONIC ("6 INFECTION 4HESE STUDIES HAVE UTILIZED BOTH NUCLEOSIDE ANALOGSANDIMMUNERESPONSEMODIFIERS;n=4HEDRUGSARESCREENED FOR ANTIVIRAL ACTIVITY AGAINST ("6 IN THE  CELL SYSTEM BEFORE TESTING INWOODCHUCKS;=!CYCLOVIRAND!:4 WHICHHADNOSELECTIVITYAGAINST ("6 IN  CELLS HAD NO ANTIVIRAL EFFECT IN THE WOODCHUCK MODEL OF ("6 INFECTION !RA !-0 WHICH HAD MODERATE ANTIVIRAL ACTIVITY IN VITRO HADSIGNIFICANTANTIVIRALACTIVITYINWOODCHUCKS ANDACTIVITYWASINCREASED BYSPECIFICLIVERTARGETING;=-OSTNUCLEOSIDEANALOGSWITHINTERMEDIATE



"UD#4ENNANTETAL

ANTIVIRAL ACTIVITY IN VITRO AGAINST ("6 HAD INTERMEDIATE ANTIVIRAL ACTIVITY IN WOODCHUCKS !N EXCEPTION WAS FIALURIDINE $ &)!5 WHICH HAD ONLY MODESTTISSUECULTUREACTIVITYINCELLSBUTINWOODCHUCKSHADPOTENT ANTIVIRALACTIVITYDURINGAMONTHPERIODOFTREATMENT$URINGAWEEK TEST HOWEVER FIALURIDINE WAS HIGHLY TOXIC AND THE CLINICAL SYNDROME IN WOODCHUCKS WAS SIMILAR TO THAT OBSERVED IN HUMANS TREATED WITH FIALURI DINE;=!NOTHERFLUORINATEDPYRIMIDINE CLEVUDINE, &-!5 ALSOHAD MODERATETISSUECULTUREACTIVITYBUTISAMONGTHEMOSTPOTENTNUCLEOSIDES IN7(6CARRIERWOODCHUCKS; = ,AMIVUDINE WHICHHADAVERYHIGHSELECTIVEINDEXAGAINST("6INVITRO WASAPOTENTANTIVIRALDRUGINWOODCHUCKSWITHFAVORABLEPHARMACOKINET ICS;=ANDWASWITHOUTTOXICITYATDOSESOFORMGKGDAYFORDAYS ;=4HEABSENCEOFEFFECTOFLAMIVUDINEONHEPATICCCC$.!WASPOSTU LATEDTOBEDUETOTHEABSENCEOFCELLDIVISION;= ,AMIVUDINEHASBEENSHOWNINTHEWOODCHUCKMODELTOACTSYNERGISTI CALLYBOTHWITHALPHA INTERFERON;=ANDWITHFAMCICLOVIR;=!NTIVIRAL POTENCYSIMILARTOLAMIVUDINEHASBEENDEMONSTRATEDIN7(6CARRIERSWITH THE CLOSELY RELATED EMTRICITABINE ;= %XTENDED LAMIVUDINE TREATMENT OF WOODCHUCKSWITHCHRONIC7(6INFECTIONSWASASSOCIATEDWITHDEVELOPMENT OFVIRALPOLYMERASEMUTATIONS;n= 4HEANTIVIRALACTIVITYOFTHENUCLEOTIDEANALOG ADEFOVIR HASBEENEVALU ATEDINTHEWOODCHUCK;=ANDADEFOVIRHASBEENSHOWNTOHAVEPOTENT ANTIVIRALACTIVITYINWOODCHUCKSWITHCIRCULATINGLAMIVUDINERESISTANT7(6 ;=4ENOFOVIR ANOTHERNUCLEOTIDEANALOG;=ANDTHEPURINENUCLEOSIDE   BETA $  AMINOPURINEDIOXOLANE!$0 ;=ALSOHAVEBEENSHOWNTO HAVESIGNIFICANTANTIVIRALACTIVITYINTHEWOODCHUCKMODEL 4HE GUANOSINE NUCLEOSIDE ENTECAVIR WAS USED IN7(6 CARRIER WOOD CHUCKSTODETERMINETHEEFFECTOFSUSTAINEDSUPPRESSIONOFVIRALREPLICATION ON HEPATOCARCINOGENESIS ;= !T  MONTHS OF AGE LABORATORY BORN AND REARED 7(6CARRIERSWEREGIVENENTECAVIRORALLYATMGKGPERDAYFOR  WEEKS AND THEN GIVEN A DOSE OF AT  MGKG PER WEEK4REATMENT WAS STOPPED AFTER A TOTAL OF  MONTHS IN SIX WOODCHUCKS AND TREATMENT WAS CONTINUED IN FIVE OTHERS FOR  MONTHS 4REATMENT RESULTED IN SIGNIFICANT REDUCTIONSINHEPATICEXPRESSIONOFVIRALANTIGENSANDOFCOVALENTLYCLOSED CIRCULAR7(6 $.!4HREE OF THE SIX WOODCHUCKS TREATED WITH ENTECAVIR FORMONTHSHADSUSTAINEDANTIVIRALRESPONSESFOLLOWINGDRUGWITHDRAWALS ANDWHENKILLEDATYEARSOFAGE HADNOEVIDENCEOF(##4HEWOODCHUCKS TREATEDFORMONTHSWEREALSOKILLEDATYEARSOFAGEANDINFOUROFFIVE THERE WAS NO EVIDENCE OF (## %NTECAVIR TREATMENT SIGNIFICANTLY DELAYED DEVELOPMENTOF(##ANDPROLONGEDSURVIVALCOMPAREDTOHISTORICAL7(6 CARRIERCONTROLSWHICHHADA YEARSURVIVALOF 0  -ENNEETAL;=TREATED7(6CARRIERWOODCHUCKSBEGINNINGATOR YEARSOFAGEFORWEEKSWITHTHEORALLYADMINISTEREDPYRIMIDINENUCLEO SIDE CLEVUDINEMGKGPERDAY ;=#ONTROLSRECEIVEDTHESALINEVEHICLE AS PLACEBO #LEVUDINE TREATED AND CONTROL WOODCHUCKS EACH WERE SUBDI

4HEWOODCHUCKMODELOFHEPADNAVIRUSINFECTION



VIDEDINTOTWOGROUPS/NESUBGROUPOFTHECLEVUDINETREATEDWOODCHUCKS RECEIVEDFOURDOSESOFALUM ADSORBED7(S!GVACCINEDURINGTHENEXT WEEKS AND A SUBGROUP OF THE PLACEBO CONTROLS RECEIVED IDENTICAL VACCINA TIONS 3UBGROUPS OF THE CLEVUDINE AND OF THE PLACEBO RECIPIENTS SERVED AS UNVACCINATEDCONTROLS 6ACCINATION RESULTED IN DETECTABLE ANTI 7(S RESPONSES IN MOST 7(6 CARRIERS BUT HAD NO EFFECT ON SERUM 7(6 $.! ON SERUM 7(S!G OR ON THE SERUM ACTIVITIES OF LIVER ENZYMES #LEVUDINE TREATED CARRIERS HAD MARKED REDUCTIONS IN SERUM 7(6 $.! AND 7(S!G AND WHEN VACCI NATED DEVELOPED A SIGNIFICANTLY MORE ROBUST ANTI 7(S RESPONSE THAN DID WOODCHUCKSNOTRECEIVINGANTIVIRALTHERAPY7(S!G SPECIFICCELL MEDIATED IMMUNERESPONSESDEVELOPEDINBOTHCLEVUDINEANDPLACEBORECIPIENTSTHAT WERE VACCINATED BUT THE IMMUNE RESPONSES WERE SIGNIFICANTLY AUGMENTED IN7(6CARRIERSTREATEDWITHCLEVUDINE7(S!GVACCINATIONOFCLEVUDINE TREATEDWOODCHUCKSDISRUPTEDVIRUS SPECIFICIMMUNETOLERANCEANDINDUCED ENHANCEDIMMUNERESPONSESCOMPAREDTOWOODCHUCKSTHATRECEIVEDEITHER CLEVUDINE OR VACCINE ALONE4HERAPY WITH THE CLEVUDINE VACCINE COMBINA TION RESULTED IN IMMUNE RESPONSE PROFILES THAT RESEMBLED THOSE OBSERVED DURINGRESOLUTIONOFEXPERIMENTAL7(6INFECTION;= )NOFTHE7(6CARRIERWOODCHUCKSTREATEDWITHCLEVUDINEWITHOR WITHOUT VACCINATION TREATMENT WAS INITIATED AT  YEAR OF AGE 3USTAINED REDUCTIONSINSERUM7(6$.!AND7(SANTIGENEMIAWEREOBSERVEDDUR INGTREATMENTANDFORAPERIODOFMONTHSFOLLOWINGWITHDRAWALOFCLEVU DINE TREATMENT ,IVER BIOPSIES WERE OBTAINED AT THE TIME TREATMENT WAS INITIATED ATTHEENDOFTREATMENTMONTHSOFAGE ANDATANDMONTHS FOLLOWINGDRUGWITHDRAWALANDMONTHSOFAGE (EPATIC7(6NUCLEIC ACIDSAND7(C!GEXPRESSIONWEREREDUCEDSIGNIFICANTLYCOMPAREDTOPLA CEBO TREATED CONTROLS THROUGHOUT THE PERIOD OF TREATMENT WITH CLEVUDINE 4HE PERCENTAGE OF HEPATIC BIOPSIES WITH FOCI OF ALTERED HEPATOCYTES WAS SIGNIFICANTLY DECREASED IN THE CLEVUDINE TREATED WOODCHUCKS COMPARED TO CONTROLSANDDEVELOPMENTOF(##WASMARKEDLYDELAYED)NTHE7(6 CARRIERS IN WHICH CLEVUDINE TREATMENT WAS INITIATED AT  YEAR OF AGE THREE YEAR SURVIVAL WAS  AND  YEARS SURVIVAL WAS  )N CONTROLS  YEAR SURVIVALWASANDYEARSURVIVAL0  )N A LONG TERM CHEMOPREVENTION STUDY   MONTH OLD7(6 CARRIERS WERETREATEDFORLIFEWITHLAMIVUDINEINITIALDOSEOFMGKGDAYFOLLOWEDBY MGKGPERDAY ANDCONTROLSRECEIVEDVEHICLEASPLACEBO;=3ERUM 7(6 $.! DECREASED GRADUALLY OVER THE FIRST FEW MONTHS BY n LOGS IN LAMIVUDINETREATEDWOODCHUCKS4HEANTIVIRALEFFECTWASSUSTAINEDFORMORE THAN  YEAR WHEN RECRUDESCENCE OF VIREMIA WAS DETECTED 2ECRUDESCENCE WAS ASSOCIATED WITH " DOMAIN MUTATIONS OF THE 7(6 POLYMERASE GENE ;=4HEDEVELOPMENTOF(##INLAMIVUDINE TREATEDWOODCHUCKSWASSIG NIFICANTLYDELAYEDANDTHEREWASANEQUIVALENTINCREASEINSURVIVALTIME4HE MEDIANTIMETOCANCERDEATHINCONTROLSWASMONTHSANDINLAMIVUDINE TREATED WOODCHUCKS  MONTHS 0  )N PLACEBO CONTROLLED CLINICAL



"UD#4ENNANTETAL

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CHRONICALLYWOODCHUCKHEPATITISVIRUS INFECTEDWOODCHUCKS!NTIMICROB!GENTS #HEMOTHERn *ACOB*2 +ORBA"% #OTE0* 4OSHKOV) $ELANEY7%TH 'ERIN*, 4ENNANT "# 3UPPRESSIONOFLAMIVUDINE RESISTANT" DOMAINMUTANTSBYADEFOVIR DIPIVOXILINTHEWOODCHUCKHEPATITISVIRUSMODEL!NTIVIRAL2ESn -ENNE3 #OTE0* +ORBA"% "UTLER3$ 'EORGE!, 4OCHKOV)! $ELANEY7% TH 8IONG3 'ERIN*, 4ENNANT"# !NTIVIRALEFFECTOFORALADMINISTRA TIONOFTENOFOVIRDISOPROXILFUMARATEINWOODCHUCKSWITHCHRONICWOODCHUCK HEPATITISVIRUSINFECTION!NTIMICROB!GENTS#HEMOTHERn -ENNE3 !SIF' .ARAYANASAMY* "UTLER3$ 'EORGE!, (URWITZ3* 3CHINAZI 2& #HU#+ #OTE0* 'ERIN*,ETAL !NTIVIRALEFFECTOFORALLYADMINIS TEREDn BETA $  AMINOPURINEDIOXOLANEINWOODCHUCKSWITHCHRONICWOOD CHUCKHEPATITISVIRUSINFECTION!NTIMICROB!GENTS#HEMOTHERn #OLONO2* 'ENOVESI%6 -EDINA) ,AMB, $URHAM3+ (UANG-, #OREY , ,ITTLEJOHN - ,OCAMINI 3 4ENNANT "# ET AL  ,ONG TERM ENTECAVIR TREATMENTRESULTSINSUSTAINEDANTIVIRALEFFICACYANDPROLONGEDLIFESPANINTHE WOODCHUCKMODELOFCHRONICHEPATITISINFECTION*)NFECT$ISn -ENNE 3 2ONEKER #! +ORBA "% 'ERIN *, 4ENNANT "# #OTE 0*  )MMUNIZATIONWITHSURFACEANTIGENVACCINEALONEANDAFTERTREATMENTWITH  FLUORO  METHYL BETA , ARABINOFURANOSYL URACIL , &-!5 BREAKS HUMORAL AND CELL MEDIATED IMMUNE TOLERANCE IN CHRONIC WOODCHUCK HEPATITIS VIRUS INFECTION*6IROLn ,IAW9 & 3UNG ** #HOW7# &ARRELL ' ,EE #: 9UEN ( 4ANWANDEE4 4AO 1- 3HUE + +EENE /. ET AL  ,AMIVUDINE FOR PATIENTS WITH CHRONIC HEPATITIS"ANDADVANCELIVERDISEASE.%NGL*-EDn

#OMPARATIVE(EPATITIS EDBY/LAF7EBERAND5LRIKE0ROTZER ¥"IRKHËUSER6ERLAG"ASEL3WITZERLAND



(EPADNAVIRUSESHAVEANARROWHOSTRANGEnDOTHEY +AI$ALLMEIERAND-ICHAEL.ASSAL 5NIVERSITY(OSPITAL&REIBURG )NTERNAL-EDICINE))-OLECULAR"IOLOGY (UGSTETTER3TR &REIBURG 'ERMANY

!BSTRACT (OSTRANGEDESCRIBESTHERANGEOFSPECIESTHATAVIRUSCANINFECTTOPRODUCTIVELYPROPAGATE ITSELF0RODUCTIVEINFECTIONREQUIRESCOMPATIBILITYBETWEENVIRUSANDHOSTMOLECULES4HUS HOST RANGE MAY BE RESTRICTED BY LACK OF APPROPRIATE PERMISSIVITY FACTORS ALTERNATIVELY HOSTSMAYACTIVELYCOUNTERACTINFECTIONUSINGRESTRICTIONFACTORS)NCOMPATIBILITYBETWEEN VIRUSANDHOSTCANMANIFESTONTHELEVELOFINDIVIDUALCELLS OFTISSUESORORGANS ANDOFTHE ENTIREORGANISM!LLHEPATITIS"VIRUSESAREHEPATOTROPIC BUTINDIVIDUALVIRUSESINFECTTHE LIVERSOFONLYSELECTEDMAMMALIANORTHOHEPADNAVIRUSES ANDAVIANAVIHEPADNAVIRUSES HOSTS (ENCE A NARROW HOST RANGE IS THOUGHT TO BE A SALIENT FEATURE OF HEPADNAVIRUSES (ERE WE BRIEFLY REVIEW GENERAL MECHANISMS OF HOST RANGE RESTRICTION AND SUMMARISE OLDERASWELLASRECENTDATAPERTAININGTOHEPADNAVIRALHOSTRANGE#LEARLY THETERMSPE CIES SPECIFIC IS INADEQUATE FOR MANY HEPADNAVIRUSES BECAUSE THEY CAN INFECT DIFFERENT SPECIESFROMONEGENUS ANDEVENSPECIESFROMDIFFERENTGENERA&ORAFEWOTHERS ONLYA SINGLESPECIES ORGENUS HASBEENIDENTIFIEDTHATSUPPORTSEFFICIENTINFECTIONHOWEVER THIS COULDASWELLRELATETOTHERESTRICTEDNUMBEROFEXPERIMENTALLYADDRESSABLETESTSPECIES 4OGETHER WITH THE UNCERTAINTY ABOUT QUANTITATIVE PHYLOGENETIC RELATIONSHIPS BETWEEN SPECIES STILL LARGELY BASED ON MORPHOLOGICAL RATHER THAN MOLECULAR CRITERIA THIS LEAVES THETERMNARROWOPENTOINTERPRETATION&INALLY FEWIFANYOFTHEHOSTMOLECULESENABLING PRODUCTIVEINFECTIONBYAHEPADNAVIRUSHAVEUNAMBIGUOUSLYBEENIDENTIFIED THEROLEOF RESTRICTIONFACTORSHASNOTYETBEENASSESSED ANDEVENONTHEVIRUSSIDETHESO CALLEDHOST DETERMINING REGIONS IN THE 0RE3 DOMAINS OF THE LARGE ENVELOPE PROTEINS APPEAR TO BE RELEVANTONLYUNDERSPECIALISEDEXPERIMENTALCONDITIONS(ENCETHISIMPORTANTASPECTOF HEPADNAVIRUSBIOLOGYISSTILLFARFROMBEINGUNDERSTOOD

)NTRODUCTION 7HILEVIRUSESCANINFECTALLFORMSOFLIFE ANINDIVIDUALORGANISMCANNOTBE INFECTED BY ALL TYPES OF VIRUSES4HOUGH NOT SURPRISING GIVEN THE DIVERSITY BETWEEN PROKARYOTIC PLANT AND ANIMAL HOSTS EVEN WITHIN ONE KINGDOM MANY VIRUSES ARE SELECTIVE WITH RESPECT TO WHAT FOR THEM CONSTITUTES A SUITABLESUSCEPTIBLE ANDANON SUITEDNON PERMISSIVE HOST ORHOSTCELL 7ITHIN METAZOAN HOSTS THREE TYPES OF SPECIFICITY TROPISM CAN BE DISTIN



+AI$ALLMEIERAND-ICHAEL.ASSAL

GUISHEDTHATFORSPECIFICCELLSCELLTROPISM THATFORSPECIFICORGANSORTIS SUESTISSUETROPISM ANDTHATFORMEMBERSOFONE BUTNOTANOTHERSPECIES GENUS FAMILY ORDERANDSOONHOSTTROPISM (OSTSPECIFICITYOFHEPATITIS" VIRUSESISTHETOPICOFTHISREVIEWHOWEVER ALLTHREEARECLOSELYINTERTWINED SUCHTHATHOSTRANGECANNOTBEDISCUSSEDINISOLATION 4HECOMMONNOTIONISTHATANARROWCELLANDTISSUESPECIFICITY NAMELY FORHEPATOCYTESANDHEPATOCYTE DERIVEDCELLS ANDANARROWHOSTRANGEARE SALIENT FEATURES OF HEPATITIS " VIRUSES "ELOW WE SUMMARISE THE EVIDENCE FAVOURING AND ATLEASTINPART QUESTIONINGTHISCONCEPTWEBRIEFLYDISCUSS THE VIRAL AND HOST FACTORS THAT IN GENERAL DETERMINE HOST RANGE IN BET TER UNDERSTOOD SYSTEMS AND RELATE THEM TO WHAT IS KNOWN FOR HEPATITIS " VIRUSES"ECAUSESEVERALCOMPREHENSIVEREVIEWSPERTAININGTOHEPADNAVIRUS BIOLOGY HAVE RECENTLY BEEN PUBLISHED ;n= WE WILL EMPHASISE UNRESOLVED ISSUES FROM BOTH EARLY AND VERY RECENT INVESTIGATIONS 4HEY REVEAL THAT EXPERIMENTAL DEFINITION OF HEPADNAVIRAL HOST RANGE IS OBSCURED BY INSUF FICIENTKNOWLEDGEONTHEINVOLVEDVIRALANDHOSTFACTORSASWELLASHOSTPHY LOGENETICRELATIONS ISSTRONGLYAFFECTEDBYTHETESTSYSTEMSUSED ANDTHUSIS MUCHLESSUNDERSTOODTHANIMPLICATEDBYPREVAILINGMODELS

'ENERALIMPORTANCEOFHOSTRANGE 7E ARE CONSTANTLY EXPOSED TO AN ENORMOUS VARIETY OF VIRUSES OF WHICH FORTUNATELY ONLYFEWAREABLETOESTABLISHAPRODUCTIVEINFECTIONINHUMANS BECAUSE OF HOST RANGE RESTRICTIONS (ENCE THIS SPECIES BARRIER PROTECTS US FROM PERMANENTLY BEING INFECTED4HE IMPORTANCE OF THIS PHENOMENON IS DRAMATICALLYHIGHLIGHTEDBYTHEOCCASIONALCROSSINGOFTHISBARRIERBYAVIRUS ANDITSPOTENTIALLYDEVASTATINGCONSEQUENCES;=NOTORIOUSEXAMPLESINCLUDE HUMANIMMUNODEFICIENCYVIRUSES()6S ;= SEVEREACUTERESPIRATORYSYN DROME3!23 CORONAVIRUS;= ORTHEIMMINENTTHREATOFANINFLUENZAPAN DEMICORIGINATINGFROM THUSFARAVIAN (.INFLUENZAVIRUSES;=)TSHOULD BE NOTED THAT NOT EVERY SPECIES CROSSING LEADS TO DISEASE 3IMIAN VIRUS  36 POSSIBLY INTRODUCED INTO THE HUMAN POPULATION BY THE POLIOVIRUS VACCINE MAYORMAYNOTBEASSOCIATEDWITHCANCER;= ANDNOINDICATIONFOR DISEASE INDUCTIONEXISTSFORSIMIANFOAMYVIRUSINFECTIONSOFHUMANS;= ! DIFFERENT CONSEQUENCE OF RELEVANCE FOR VIROLOGICAL AND MEDICAL RESEARCH IS THAT HOST RANGE RESTRICTIONS CAN PREVENT THE ESTABLISHMENT OF ANIMALMODELSFORINFECTIONWITHAHUMANVIRALPATHOGEN FORWHICH("6 REPRESENTSANEMINENTEXAMPLE

-OLECULARDETERMINANTSOFVIRALHOSTRANGE 6IRAL INFECTION AND DEFENSE AGAINST INFECTION DEPEND ON INTERACTIONS BETWEEN VIRAL AND HOST COMPONENTS WHICH THEREFORE MUST BE MATCHING

(EPADNAVIRUSHOSTRANGE



4WOFUNDAMENTALLYDISTINCTMECHANISMSRESTRICTINFECTABILITY%ITHERALACK OFFACTORSREQUIREDFORTHEVIRUSTOCOMPLETEITSINFECTIOUSCYCLE@PERMIS SIVITY FACTORS OR THE PRESENCE OF HOST FACTORS THAT ACTIVELY BLOCK THAT CYCLE@RESTRICTIONFACTORS THELATTERMAYBEDIVIDEDINTOFACTORSTHATARE CONSTANTLYPRESENTINNATE ANDTHOSETHATAREINDUCEDINRESPONSETOTHE ENCOUNTER WITH A SPECIFIC VIRUS ADAPTIVE  %VIDENTLY CELLS FROM DIFFERENT HOSTS AND FROM DIFFERENT TISSUES WITHIN ONE HOST DIFFER IN THEIR EXPRES SIONPROFILESADDITIONALDIVERSIFICATIONCOMESINBYCHANGESRELATEDTOTHE CELL CYCLEANDDIFFERENTIATIONSTATUS(ENCEPERMISSIVITYFACTORSMAYEITHER COMPLETELY ORTEMPORARILYBEABSENT ORDIFFERBETWEENHOSTSPECIESINTHEIR EXACT COMPOSITION SUCH THAT THEY CANNOT PRODUCTIVELY INTERACT WITH THE CORRESPONDINGVIRALCOMPONENTTHESAMEHOLDS CONVERSELY FORRESTRICTION FACTORS

(OSTRANGERESTRICTIONSBYLACKOFHOSTFACTORSREQUIRED BYTHEVIRUS &AILURE TO COMPLETE ANY ONE OF THE INDIVIDUAL INFECTIOUS CYCLE STEPS FOR PHYSICALLACKOF ORLACKOFCOMPATIBILITYWITH ACELLULARFACTORINVOLVEDWILL EXCLUDE A CELL OR ORGANISM FROM BEING A HOST FOR THAT VIRUS 2ELATED SPE CIESHAVEARELATEDGENETICOUTFIT ANDTHECLOSERTHERELATIONTHEHIGHERTHE SIMILARITYBETWEENINDIVIDUALGENESANDGENEPRODUCTS(ENCESUSCEPTIBIL ITYTOACERTAINVIRUSINONEHOSTSPECIESWILLMOSTEASILYBEEXTENDABLETO CLOSELYRELATEDHOSTS4HEIMPORTANCEOFMATCHBETWEENVIRALANDCELLULAR FACTORSISALSOHIGHLIGHTEDBYTHEIMPACTONINFECTABILITYOFINDIVIDUALPOLY MORPHISMSINSOMECELLULARGENESAFAMOUSEXAMPLEAREHUMANSCARRYING ANON FUNCTIONALALLELEOFTHE()6 CORECEPTOR##2GENE ##26; =)NTERESTINGLY THISALLELEALSODECREASESTHELIKELIHOODFORHEPATITIS"TO BECOMECHRONIC THOUGHPROBABLYBYANIMMUNOMODULATORYRATHERTHANA DIRECT MECHANISM ;= IN CONTRAST AN INTACT ##2 GENE PROTECTS AGAINST 7EST.ILEVIRUSINFECTION;= .ONETHELESS VIRUSES DIFFER GREATLY IN THEIR HOST SPECIFICITIES 6ESICULAR STOMATITISVIRUS636 INFECTSCELLSFROMAVERYWIDERANGEOFSPECIES INCLUD INGVERTEBRATES INVERTEBRATESANDEVENINSECTSSOMEMURINERETROVIRUSES IN CONTRAST ARESOMUCHRESTRICTEDTHATTHEYINFECTONEBUTNOTANOTHERSTRAIN OFMICE!SOUTLINEDBELOW HEPADNAVIRUSHOSTSPECIFICITYSEEMSTOBEINTER MEDIATEBETWEENTHESEEXTREMES &OR ANY VIRUS INCLUDING ("6 THE EVENTS DURING PRODUCTIVE INFECTION CAN BROADLY BE CATEGORISED INTO ATTACHMENT ENTRY UNCOATING OF THE VIRAL GENOME GENOME REPLICATION AND EXPRESSION OF GENE PRODUCTS AND ASSEM BLYANDEGRESSOFPROGENYVIRIONS-OSTOCCURATDIFFERENTSITESINTHECELL HENCE THE IMPORTANCE OF INTRACELLULAR TRAFFICKING IN VIRUS REPLICATION AND CONSEQUENTLY THE DEPENDENCE ON THE INVOLVED CELL FACTORS IS INCREASINGLY RECOGNISED;=



+AI$ALLMEIERAND-ICHAEL.ASSAL

!TTACHMENTANDENTRY %ACHVIRUSMUSTBINDTOASUITABLEHOSTCELL ANDTHENMUSTGETACCESSTOTHE CYTOPLASMBYCROSSINGEITHERTHEHOSTCELLPLASMAMEMBRANE ORANINTER NALnUSUALLYENDOSOMALnMEMBRANEFORENVELOPEDVIRUSESTHISGENERALLY INVOLVESMEMBRANEFUSIONEVENTS"INDINGANDFUSIONACTIVITIESMAYRESIDE INASINGLEPROTEIN ASWITH636'PROTEIN ORONSEPARATEPOLYPEPTIDES /BVIOUSLY THE INITIAL BINDING REQUIRES INTERACTIONS BETWEEN MOLECULES THATAREEXPOSEDONTHESURFACESOFTHEVIRUSANDOFTHECELL COMMONLY NAMEDVIRALATTACHMENTPROTEINS ORVIRALRECEPTORS ANDCELLULARRECEPTORS 4HESECANBEDIFFERENTCLASSESOFMOLECULES INCLUDINGPROTEINS LIPIDS AND SUGARS&ORMANYVIRUSES THOUGHNOTTHEHEPADNAVIRUSES THEHOSTINTERAC TIONPARTNERSOFTHEIRATTACHMENTANDFUSIONPROTEINSAREKNOWN;= IN SEVERALCASESEVENINATOMICDETAIL;=%XAMPLESINCLUDE()6 GP AND #$ INFLUENZA VIRUS HAEMAGGLUTININ (! AND SIALIC ACID RESIDUES &OR PROTEIN RECEPTORS IT IS OBVIOUS THAT THEIR AMINO ACID SEQUENCES WILL VARY BETWEEN HOST SPECIES AND HENCE MAY ACT AS IMPORTANT HOST RANGE RESTRICTIONELEMENTS.OTABLY EVENLESSCOMPLEXBIOLOGICALSTRUCTURESCAN EXERT SUCH A RESTRICTIVE FUNCTION AS SHOWN BY THE DIFFERENTIAL RECOGNI TIONOF_ VERSUS_ LINKAGESTOGALACTOSEINTHESIALICACIDRECEPTORS USEDBYAVIANVERSUSHUMANINFLUENZAVIRUSES;=!SECONDINCREASINGLY APPRECIATED FEATURE IS THAT OFTEN PERHAPS ALWAYS MORE THAN ONE HOST SURFACE MOLECULE IS INVOLVED 3UCH SECONDARY MOLECULES FOR INSTANCE EXTRACELLULAR MATRIX COMPONENTS SUCH AS GLYCOSAMINOGLYCANS '!'S MAYGENERALLYHELPCONCENTRATINGTHEVIRUSONTHECELLSURFACE ORBEMORE SPECIFIC OFTENSEQUENTIALLY ACTINGCO RECEPTORSTHATAREESSENTIALFORPRO DUCTIVE ENTRY7ELL KNOWN EXAMPLES INCLUDE FOR NON ENVELOPED VIRUSES THEINITIALBINDINGOFTHEADENOVIRUSFIBERPROTEINTOTHE#OXSACKIE 6IRUS !DENOVIRUSRECEPTOR#!2 ANDTHESUBSEQUENTINTERACTIONOFTHEPEN TON BASE PROTEIN WITH CELLULAR INTEGRINS ;= AND FOR ENVELOPED VIRUSES THE()6 RECEPTORSANDCO RECEPTORS#$AND#8#2AND##2;= /FNOTE RELATIVELYSMALLALTERATIONSINAVIRALPROTEINCANLEADTOTHEUSE OF ALTERNATIVE HOST RECEPTORS ;= AND THEREFORE CONTRIBUTE TO EXTEND THEVIRUSHOSTRANGE&INALLY VIRUSHOSTCELLRECEPTORINTERACTIONSMAYBE MODULATEDINDIRECTLYBYAUXILIARYPROTEINS&ORMANYVIRUSES FUSIONACTIV ITYDEPENDSONABALANCEDPROTEOLYTICACTIVATIONOFTHEFUSIONPROTEIN4HE PERTINENTEXAMPLEISTHEHAEMAGGLUTININ(! OFINFLUENZAVIRUSESANDITS DEPENDENCEONPROPERLYTIMEDCLEAVAGEINTO(!AND(!;=(ENCE AVAILABILITYOFSUITABLEPROTEASESATTHERIGHTCONCENTRATIONANDLOCATION CANWELLAFFECTHOSTRANGE

(EPADNAVIRUSHOSTRANGE



5NCOATINGOFTHEVIRALGENOME REPLICATIONANDFORMATIONOF PROGENYVIRIONS 4HE STEPS FOLLOWING ENTRY CAN AS WELL PROFOUNDLY AFFECT VIRAL HOST RANGE 0OXVIRUSES FOR INSTANCE USING UBIQUITOUSLY PRESENT MOLECULES POSSIBLY '!'S ASRECEPTORSCANENTERMANYDIFFERENTCELLS4HEIRNARROWHOSTRANGE 6ARIOLAVIRUSINFECTSEXCLUSIVELYHUMANS MUSTTHEREFORERELATEMOSTLYTO DOWNSTREAMINTRACELLULAREVENTS;=3OMEOFTHEBASICCELLULARMACHINERY FOR TRANSCRIPTION TRANSLATION AND PROTEIN FOLDING ; = IS PROBABLY UNI VERSALHOWEVER THEONGOINGSEARCHFORAMOUSEMODELOF()6 INFECTION ;=ISREVEALINGANEVERINCREASINGNUMBEROFHOST SPECIFICFACTORS;=THAT LACKCOMPATIBILITYWITHCOMPONENTSOFTHEHUMANVIRUS%XAMPLESINCLUDE PREINTEGRATION COMPLEX NUCLEAR IMPORT ;= AND THE 4AT PROTEIN WHICH TOGETHERWITHTHEHOSTFACTORSCYCLIN4ANDACYCLINKINASE#DK BINDSTO THE4!2ELEMENTONNASCENTVIRAL2.! ENHANCINGTHERATEOFVIRAL2.! TRANSCRIPTIONBY2.!POLYMERASE))()6 4ATINTERACTSPRODUCTIVELYWITH HUMAN BUT NOT MURINE CYCLIN 4 ;= !LSO ()6  ASSEMBLES AND BUDS POORLY IN MOUSE CELLS SUGGESTING THAT COMPONENTS OF OR ASSOCIATED WITH THEENDOSOMALSORTINGCOMPLEXREQUIREDFORTRANSPORT%3#24 CONTRIBUTE TO SPECIES TROPISM ;=4HIS MACHINERY IS PROBABLY ALSO INVOLVED IN ("6 MORPHOGENESIS;n=HOWEVER THESINGLEMOSTIMPORTANTSPECIES SPECIFIC BLOCKSTOHEPADNAVIRUSINFECTIONAPPEARTOOPERATEDURINGTHEINITIALSTEPS OFINFECTIONSEEBELOW 

0RESENCEOFHOSTRESTRICTIONFACTORS #ELLS MAY ACTIVELY COUNTERACT VIRAL INFECTION BY INNATE RESTRICTION FACTORS ADAPTIVERESPONSES THOUGHCRUCIAL ARENOTCONSIDEREDHERE)NNATERESTRIC TION FACTORS TYPICALLY ACT IN A DOMINANT SATURABLE FASHION IE INHIBITION CANBEOVERCOMEBYHIGHDOSESOFVIRUS@ABROGATION ANDTHEYCANTARGET DIVERSESTEPSOFVIRALREPLICATION ASISBESTKNOWNFORRETROVIRUSES;n= #LASSIC EXAMPLES ARE THE ENDOGENOUS RETROVIRAL GENE PRODUCTS &V WHICH RESTRICTS &RIEND MURINE LEUKAEMIA VIRUS BY RECEPTOR BLOCKADE AND &V A 'AG LIKEPROTEINTHATTARGETSTHECAPSIDPROTEINSOFSOMERETROVIRUSESAND INTERFERESWITHPROPERFUNCTIONINGOFTHEPREINTEGRATIONCOMPLEX!NOTHER WIDELYPRESENTRESTRICTIONSYSTEMISBASEDONTHEFAMILYOFTRIPARTITESEQUENCE MOTIF42)- PROTEINS;=WHICHTYPICALLYCONTAINA2).'DOMAIN FOUND INMANY%UBIQUITINLIGASES ONEORTWO"BOXES ANDACOILED COILREGION PLUSDIFFERENT#TERMINALDOMAINS4HEMOSTFAMOUSOFTHEABOUT42)- FAMILY MEMBERS ;= IS 42)-_ A SPECIES SPECIFIC RESTRICTION FACTOR FOR VARIOUS IMMUNODEFICIENCY VIRUSES AND ALSO SIMPLE RETROVIRUSES ;= FOR INSTANCE RHESUSMONKEY BUTNOTHUMAN 42)-_RESTRICTS()6 AND()6  42)-_ ALSO TARGETS THE CAPSID PROTEIN AND PREVENTS PROPER REVERSE TRANSCRIPTION PROBABLYBYPREMATUREUNCOATING ANDPOSSIBLYALSOTHROUGH



+AI$ALLMEIERAND-ICHAEL.ASSAL

DEGRADATION OF 'AG POLYPROTEIN PRECURSORS ;=4HIS MECHANISM MAY BE ANTAGONISED BY THE HOST PROLINE ISOMERASE CYCLOPHILIN ! #YP! WHICH AUGMENTS()6 INFECTIONINHUMANCELLSBUTINHIBITSREPLICATIONINMONKEY CELLS;=/THER42)-FAMILYMEMBERSAREALSOINVOLVEDINANTIVIRALRESIS TANCE;= !NOTHERRESTRICTIONSYSTEMISBASEDONTHE!0/"%#FAMILYOFCYTIDINE DEAMINASES;= NAMEDAFTERTHEFOUNDINGMEMBER!0/"%#WHICHEDITS THEM2.!FORAPOLIPOPROTEIN"!0/"%#'TARGETSINSTEADSINGLE STRAND ED $.! FOR INSTANCE RETROVIRUS MINUS STRAND $.! AND INTRODUCES VARI OUS #5 MUTATIONS RESULTING IN '! HYPERMUTATION IN THE PLUS STRAND 4HE5 RESIDUESRENDERTHE$.!UNSTABLE ANDHYPERMUTATIONCANPREVENT FORMATIONOFFUNCTIONALGENEPRODUCTS4HELENTIVIRAL6IFGENEPRODUCTSPRO TECT THE VIRUSES BY INDUCING !0/"%#' DEGRADATION SPECIES SPECIFICITY RESULTSMAINLYFROMTHEABILITY ORINABILITY OFAGIVEN!0/"%#PROTEINTO INTERACTWITHTHERESPECTIVE6IFPROTEIN;=!0/"%#'ANDOTHERFAMILY MEMBERS IFOVEREXPRESSEDINHEPATICCELLLINES ALSORESTRICT("6THOUGHTHE DEAMINASEACTIVITYISNOTREQUIRED; =(EPADNAVIRUSESDONOTSEEMTO ENCODEA6IF LIKEANTI !0/"%#ACTIVITYHENCEPOTENTIALHOSTRANGERESTRIC TION WOULD HAVE TO ACT DIRECTLY VIA CAPSID !0/"%# INTERACTIONS ! ROLE FOR!0/"%#INAVIHEPADNAVIRUSINFECTIONSISUNLIKELYBECAUSE!0/"%# PROTEINS LIKE!0/"%# APPEARTOBEMAMMAL SPECIFIC;= 9ET ANOTHER INNATE FACTOR RESTRICTION FACTOR IS THE ZINC FINGER ANTIVIRAL PROTEIN :!0 WHICH TARGETS VIRAL 2.! FOR DESTRUCTION BY THE EXOSOME 2.! DEGRADATION MACHINERY AS SHOWN FOR RETROVIRUSES AND 3INDBIS VIRUS ; = AND RECENTLY MADE LIKELY FOR FILOVIRUSES ;= 7HETHER :!0 CAN AFFECTHOSTRANGEISCURRENTLYNOTKNOWN ! FURTHER COMPLEX INNATE DEFENSE SYSTEM AGAINST VIRUSES AND OTHER PATHOGENS CONSISTS OF THE VARIOUS4OLL LIKE RECEPTORS 4,2S  2ECOGNITION OFNON SELF@PATHOGEN ASSOCIATEDMOLECULARPATTERNS0!-0S BYTHESEPRO TEINS LOCATEDINTHEPLASMAMEMBRANE4,2 ORINENDOSOMALMEMBRANES MOSTOTHER4,2S INDUCESANTIVIRALSIGNALINGPATHWAYSTHATACTIVATE EG .&K" OR INTERFERON REGULATORY FACTOR  )2& LEADING TO EXPRESSION OF ANTIVIRALCYTOKINESANDINTERFERONS;=4HEVIRAL0!-03MAYBEPROTEINS 4,2 4,2 OR NUCLEIC ACIDS SUCH AS DS2.! 4,2 SS2.! 4,2 4,2 OR DS$.! 4,2  2ECENTLY DISCOVERED CYTOPLASMIC SENSING SYSTEMS INCLUDE THE 2.! HELICASES RETINOIC ACID INDUCED GENE ) 2)' ) WHICHAPPEARSTORECOGNISEUNCAPPEDDOUBLE STRANDEDVIRAL2.!BEARING  TRIPHOSPHATES EG FROMINFLUENZA 3ENDAIORFLAVIVIRUSESINCLUDING(#6 ;= ANDMELANOMADIFFERENTIATIONASSOCIATEDGENE-$! WHICHSENSES  PROTECTED 2.! EG FROM PICORNAVIRUSES ;= "OTH ACTIVATE THROUGH THEIRCASPASERECRUITMENTDOMAINS#!2$ AMITOCHONDRIA BOUNDPROTEIN VARIOUSLYKNOWNAS#!2$ADAPTORINDUCING)&. `#!2$)& INTERFERON ` PROMOTER STIMULATOR  )03  VIRUS INDUCED SIGNALING ADAPTOR 6)3! OR MITOCHONDRIAL ANTIVIRAL SIGNALING -!63 ALSO LEADING TO .& g" AND )2& )2& MEDIATEDINTERFERONINDUCTION(OWMUCHTHESEANTIVIRALFAC

(EPADNAVIRUSHOSTRANGE



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+AI$ALLMEIERAND-ICHAEL.ASSAL

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+AI$ALLMEIERAND-ICHAEL.ASSAL

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+AI$ALLMEIERAND-ICHAEL.ASSAL

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+AI$ALLMEIERAND-ICHAEL.ASSAL

DETAIL ISINFECTIONINHIBITIONBY0RE3 DERIVEDPEPTIDES;=0SEUDOTYPESARE VIRUSESTHATCARRYANENVELOPEWHICHTHEYDONOTENCODETHEMSELVES USUALLY PROVIDEDINTRANSFROMASUITABLEEXPRESSIONVECTORPSEUDOTYPEDASWELLAS CHIMERICVIRIONSCANBEGENERATEDBYTRANSFECTIONOFSUITABLECELLLINES SUCH AS(UHOR(EP'FORTHEPRIMATE AND,-(FORTHEBIRD("6S!NADVAN TAGEISTHATONLYMINIMALCHANGESINTHEGENOMEAREREQUIREDTOKNOCKOUT THE OPEN READING FRAMES FOR THE LARGE AND IF DESIRED ALSO SMALL ENVELOPE PROTEINS THIS PREVENTS PROBLEMS POTENTIALLY ARISING FROM MORE COMPLEX MANIPULATIONS THAT MIGHT HAVE UNFORESEEN CONSEQUENCES ON THE OVERLAP PING0GENE&IG" ANDTHENUMEROUSCIS ELEMENTSDISTRIBUTEDOVERTHE HEPADNAVIRALGENOME;=(OWEVER BECAUSEPSEUDOTYPEDVIRUSESDONOT ENCODETHEIRENVELOPEPROTEINS INFECTIONISRESTRICTEDTOASINGLEROUNDAND THEREFORECANONLYBEMONITOREDINCULTUREDCELLS NOTINVIVO4HEREVERSE ISTRUEFORCHIMERICVIRUSESHOWEVER PRINCIPALREPLICATIONCOMPETENCEAND PROPERENVELOPMENT;=CANBETESTEDBEFOREHANDBYTRANSFECTION "ECAUSE OF THE LACK OF SUITABLE HOST ANIMALS FOR THE PRIMATE ("6S ALL STUDIESSOFARHAVEUSEDTHEPSEUDOTYPINGAPPROACH SOMETIMESWITH($6 INSTEAD ("6 ; n= AND PRIMARY HUMAN OR PRIMATE HEPATOCYTES ORRECENTLY THE(EPA2'CELLLINE;=-UTATIONSINTHEENVELOPEPROTEINS INCLUDEDSYSTEMATICDELETIONSIN0RE3 ORIN3; = ORTHEREPLACEMENT OFSEGMENTSWITHTHEHOMOLOGOUSSEGMENTSFROMANOTHERHEPADNAVIRUS USU ALLY7-("6; =#OLLECTIVELY THEMOSTRECENT COMPREHENSIVEDATA INDICATETHATALLINFECTIVITYDETERMINANTSWITHIN("60RE3ARECONFINEDTO THEFIRSTAMINOACIDS;= WITHAPOSSIBLEROLEFORTHEANTIGENICLOOPIN3 ;=BUTNOTTHE4,-MOTIFIN0RE3("6PSEUDOTYPEDWITHA7-("6 DERIVEDENVELOPEDISPLAYEDREDUCEDINFECTIVITYFORPRIMARYHUMANHEPATO CYTES YETINFECTIVITYWASRESTOREDWHENTHE.TERMINALAMINOACIDSWERE DERIVEDFROM("60RE3;=CONVERSELY REPLACEMENTOFTHISSEGMENTBY THATOF7-("6INTHECONTEXTOFTHE("6,PROTEINREDUCEDINFECTIVITY 0ARTLYCONGRUENTDATAHAVEBEENOBTAINEDUSINGTHE($6PSEUDOTYPESYS TEM;=INTHATTHEFIRST7-("60RE3AMINOACIDSIMPLANTEDINTOTHE ("6,PROTEINREDUCEDINFECTIVITYFORHUMANHEPATOCYTESHOWEVER INTHE REVERSESETTINGTHEFIRST("60RE3AMINOACIDSIN7-("6,ONLYPART LYINCREASEDINFECTIVITYFORTHEHUMANCELLSMOSTSURPRISINGLY HOWEVER THIS CHIMERIC,PROTEINHADASTRONGLYENHANCEDINFECTIVITYFORSPIDERMONKEY HEPATOCYTES TOALEVELHIGHERTHANTHATPROVIDEDBYACOMPLETE7-("6 ,PROTEIN/THERTHANSUGGESTINGTHAT0RE3CONTAINSSEPARATEDOMAINSTHAT INTERACTWITHDISTINCTCELLRECEPTORS INTERPRETATIONOFTHESERESULTSREMAINS ENIGMATIC ANDFARTHER REACHINGINVIVOEXPERIMENTSARECURRENTLYNOTFEA SIBLEWITHTHEPRIMATE("6S !LSOTHERODENT("6SARENOTIDEALFORSUCHSTUDIESBECAUSENOCELLLINES EXIST THAT UPON TRANSFECTION SUPPORT EFFICIENT PRODUCTION OF RECOMBINANT VIRUSES OR PSEUDOTYPES (ENCE THERE IS ONLY ONE EARLY STUDY ON CHIMERIC '3(6S IN WHICH ABOUT  OR ABOUT  OF THE 3 GENE WERE REPLACED BY7(6SEQUENCETHESEVIRUSESWEREINFECTIOUSFORGROUNDSQUIRRELSUPON

(EPADNAVIRUSHOSTRANGE



INTRAHEPATIC$.!INOCULATION;= SUGGESTINGTHAT3DOESNOTDETERMINE HOSTRANGE $UETOTHESELIMITATIONS MOSTSTUDIESONHEPADNAVIRALHOSTRANGEHAVE BEENPERFORMEDWITHAVIHEPADNAVIRUSESALTHOUGH UNTILRECENTLYSEEBELOW THEPOTENTIALOFTHISSYSTEMFORTRUEINVIVOSTUDIESHASNOTBEENEXPLOITED -OST INFLUENTIAL FOR THE ENTIRE FIELD HAS BEEN A PSEUDOTYPE STUDY BY )SHIKAWA AND 'ANEM ;= "ASED ON THE HIGH INFECTIVITY OF $("6 BUT ABOUT FOLDLOWERINFECTIVITYOFHERON("6(("6 FORPRIMARY0EKIN DUCKHEPATOCYTES A(("6GENOMEDEFICIENTFORSURFACEPROTEINPRODUCTION WASPSEUDOTYPEDWITHCHIMERIC(("6ENVELOPEPROTEINSINWHICHVARIOUS PARTS OF THE 0RE3 REGION WERE REPLACED BY THE CORRESPONDING $("6 0RE3 SEQUENCES!LL CONSTRUCTS YIELDED ENVELOPED VIRIONS AFTER TRANSFECTION INTO ,-( CELLS WHICH WERE THEN USED TO INOCULATE PRIMARY DUCK HEPATOCYTES FORMATION OF INTRACELLULAR REPLICATIVE INTERMEDIATES INDICATED THAT THE ENTIRE $("6 0RE3 SEQUENCE AND SEGMENTS n n n BUT NOT n RESCUED INFECTIVITY FROM THIS IT WAS CONCLUDED THAT RESIDUES  TO  DETERMINE THE HOST RANGE OF AVIAN ("6S!N ADDITIONAL CHIMERA BEAR INGONLY$("6AMINOACIDSnWASAPPARENTLYALSOINFECTIOUSFORDUCK HEPATOCYTES4)SHIKAWA PERSCOMMUNICATION AND0RE3 DERIVEDPEPTIDES SPANNING SLIGHTLY MORE THAN THIS REGION $("6 0RE3  PARTICULARLY IF MYRISTOYLATEDLIKENATURAL0RE3 INHIBITED$("6INFECTIONOFDUCKHEPATO CYTES;=4HEREFORE THEPREVAILINGVIEWISTHAT0RE3AMINOACIDSn OR POSSIBLYn CONSTITUTETHEHOSTDETERMININGREGIONOFTHEAVIAN("6S;   =.OTABLY THISREGIONISNOTINVOLVEDINCARBOXYPEPTIDASE$BINDING &IG ANDAMYRISTOYLATEDPEPTIDECORRESPONDINGTOTHEHERON("60RE3 SEQUENCEnBLOCKED$("6INFECTIONOFDUCKHEPATOCYTESASEFFICIENTLYAS THEAUTOLOGOUS$("60RE3PEPTIDE;=%VIDENTLY THISISNOTEASILYRECON CILEDWITHASPECIFICROLEOFTHIS0RE3SEGMENTINDETERMININGHOSTRANGE )NORDERTOSHEDMORELIGHTONTHERELEVANCEOFTHESEDATAFORATRUEIN VIVOINFECTION WEGENERATEDTWOSERIESOFCHIMERICDUCKANDHERON("6S BEARING INCIS THESHORTANDLONGFORMSOFTHEPROPOSEDHOSTDETERMINING 0RE3REGIONSFROMTHEOTHERVIRUS&IG BOTTOM BEINGABLETOINHERITTHE CHIMERICENVELOPEPROTEINSTOTHEIRPROGENY THESEVIRUSESARESUITABLEFOR INVIVOSTUDIES;=AND$ALLMEIERAND.ASSAL SUBMITTED "ASEDONTHE PUBLISHED PSEUDOTYPE DATA WE EXPECTED THAT IMPLANTATION OF THE HERON SEQUENCE INTO $("6 WOULD REDUCE AND CONVERSELY IMPLANTATION OF THE SUPPOSED $("6 0RE3 HOST DETERMINING REGION INTO HERON ("6 WOULD INCREASE INFECTIVITY FOR DUCK HEPATOCYTES AND DUCKLINGS !LL THE CHIMERIC VIRUSES UPON TRANSFECTION WERE FULLY REPLICATION COMPETENT AND FORMED COMPARABLE AMOUNTS OF ENVELOPED VIRIONS AS WILD TYPE $("6 (OWEVER NONEOFTHEHERON("6CHIMERASCONTAINING$("60RE3SEGMENTSn n n AND n AND OR EVEN THE ENTIRE 0RE3 REGION DISPLAYED SIGNIFICANTLY INCREASED INFECTIVITY FOR PRIMARY DUCK HEPATOCYTES OVER WILD TYPE HERON ("6 OR WAS ABLE TO ESTABLISH IN VIVO INFECTIONS IN DUCKLINGS 2EPEATINGTHEORIGINALPSEUDOTYPEEXPERIMENTS THECOMPLETE$("60RE3



+AI$ALLMEIERAND-ICHAEL.ASSAL

REGION ASWELLASSEGMENTSnANDn THOUGHNOTnASREPORTED ANDnASINFERRED CLEARLYINCREASEDINFECTIVITYFORHEPATOCYTES4HUSIN OURHANDSSUBSTANTIALPARTSOF THOUGHNOTALL THEPREVIOUSLYPUBLISHEDDATA WERE REPRODUCED WITH THE PSEUDOTYPE SYSTEM n BUT NOT WITH THE CHIMERIC VIRUSES4HEREISCURRENTLYNOTRIVIALEXPLANATIONFORTHISDIFFERENCE %VENMOREDISTURBINGARETHEDATAOBTAINEDWITH$("6GENOMESCAR RYINGTHECORRESPONDINGHERON("60RE3SEQUENCESINTHEIR,PROTEINS!S ANTICIPATED A REDUCTION IN INFECTIVITY FOR DUCK HEPATOCYTES WAS SEEN WITH CHIMERASINWHICHTHE$("60RE3SEGMENTSn ANDALSOITSSUBSEGMENT n WERE REPLACED BY HERON ("6 SEQUENCE HOWEVER REPLACEMENT OF RESIDUESnHADNONEGATIVEIMPACTONINFECTIVITYFORDUCKHEPATOCYTES (ENCE IN THIS SETTING THE SHORT FORM OF THE SUPPOSED HOST DETERMINING REGIONDIDNOTAFFECTHOSTRANGE-OSTSURPRISING HOWEVER WERETHEINVIVO INFECTIONDATA!LLTHREEVIRUSES INCLUDINGTHOSEWITHTHELARGEHETEROLOGOUS 0RE3 SEGMENTS AND POOR INFECTIVITY FOR CULTURED HEPATOCYTES WERE ABLE TO INFECT DUCKLINGS IN VIVO4HE CHIMERA WITH THE ENTIRE ORIGINALLY PROPOSED DUCKSPECIFICITYDETERMININGREGIONnREPLACEDBYHERONVIRUSSEQUENCE WASFURTHERCHARACTERISEDANDSHOWNTOESTABLISHHIGH TITERED CHRONICINFEC TIONSINDUCKLINGS ANDTOBEBOTHHORIZONTALLYANDVERTICALLYTRANSMITTABLE 1UANTITATIVEMONITORINGDURINGTHEEARLYINFECTIONPHASEALSOSHOWEDKINET ICSOFVIRALSPREADTHATWEREEQUALTO OREVENFASTERTHANTHOSEFORWILD TYPE $("6 4HUS ALTHOUGH SERIOUSLY HANDICAPPED IN CELL CULTURE THIS VIRUS WITHOUTTHEPROPERHOSTDETERMININGREGIONFORDUCKSWASASINFECTIOUSIN VIVOASITSAUTHENTIC$("6PARENT4HISDEFIESTHEVIEWTHATCULTUREDCELLS ARELESSRESTRICTIVETHANANINTACTHOSTORGANISMS ANDITSERIOUSLYQUESTIONS THECURRENTCONCEPTOFASHORTAMINOACIDSEQUENCEIN0RE3ASTHECRUCIAL FACTORINHOSTRANGEDETERMINATIONOFAVIAN ANDPOSSIBLYALSOMAMMALIAN ("6S 5NLESS THE CHIMERIC VIRUS HAS SWITCHED TO A DIFFERENT RECEPTOR THE DATASTRONGLYSUGGESTTHAT INVIVO THEHERON("60RE3SEQUENCEINTERACTS AS WELL WITH THE DUCK RECEPTORS AS THE AUTHENTIC $("6 0RE3 SEQUENCE .OTABLY THIS IS IN ACCORD WITH THE LACK OF SPECIES SPECIFIC RESTRICTIONS SUG GESTED BY THE COMPARABLY EFFICIENT INHIBITION OF $("6 INFECTION BY BOTH DUCK("6ANDHERON("60RE3PEPTIDES;= ANDTHESTRONGBINDINGOF THEDOWNSTREAM0RE3REGIONSFROMBOTHVIRUSESTODUCKCARBOXYPEPTIDASE $;=%VIDENTLYCULTUREDHEPATOCYTESARENOTTHEULTIMATESYSTEMFORDEFI NITESTATEMENTSONWHATDETERMINESHEPADNAVIRALHOSTRANGEMOREOVER THE ENTIRECURRENTCONCEPTOFASHORT0RE3SEGMENTASHOSTDETERMININGREGION MAYNEEDREEVALUATION

#ELLULARRESTRICTIONFACTORSASDETERMINANTSFORHEPADNAVIRAL HOSTRANGE !NOTHERUNRESOLVEDQUESTIONISTHESUSPICIOUSNON SUSCEPTIBILITYOF-USCOVY DUCKS FOR IN VIVO $("6 INFECTION ; = IN CELL CULTURE INFECTION IS

(EPADNAVIRUSHOSTRANGE



NOT COMPLETELY BLOCKED AS IS IT WITH CHICKEN HEPATOCYTES BUT IS SIMILARLY INEFFICIENT AS INFECTION OF 0EKIN DUCK HEPATOCYTES WITH HERON ("6 ;= 0HYLOGENY PROVIDES NO CLUE AS TO WHY THE GENUS #AIRINA SHOULD NOT BE INFECTABLEWHILE-ANDARINDUCKSCANHOSTA$("6 LIKEVIRUSSEEABOVE  (ENCE-USCOVYDUCKSMAYFORTUITOUSLYLACKAFUNCTIONALPERMISSIVITYFAC TOR OR POSSESS A RESTRICTION FACTORS THAT ISARE ABSENT FROM 0EKIN AND OTHER$("6 INFECTABLEDUCKSPECIES4HATNON PERMISSIVENESSCAN ATLEAST INCULTUREDHEPATOCYTES BEPARTIALLYOVERCOMEBYHIGHDOSESOFVIRUSWOULD BECOMPATIBLEWITHOUT TITRATIONABROGATION OFSUCHANEGATIVEFACTORBUT ALSOWITHTHEABSENCEOF ORINCOMPATIBILITYWITH HOSTPERMISSIVITYFACTORS !SAFIRSTSTEPTOWARDSDISTINGUISHINGBETWEENTHESEPOSSIBILITIES WERESORT EDTOACLASSICGENETICAPPROACH-USCOVYAND0EKINDUCKSCANINTERBREED ATTESTINGTOTHEIRCLOSEPHYLOGENETICRELATIONSUCHMULEDUCKSAREPRODUCED INLARGENUMBERSINTHEFOODINDUSTRY!-USCOVYDRAKEWASCROSSEDWITH CHRONICALLY$("6INFECTED0EKINDUCKFEMALES ANDTHEOFFSPRINGEMBRYOS WERE ANALYSED FOR $("6 INFECTION + $ALLMEIER 5 3CHULTZ - .ASSAL UNPUBLISHEDDATA &OUROFFOUREMBRYOSTESTEDSHOWEDCLEARLYDETECTABLE THOUGH SLIGHTLY VARYING LEVELS OF TYPICAL $("6 REPLICATIVE INTERMEDIATES IN THEIR LIVERS!S & HYBRIDS THESE EMBRYOS CARRIED ONE COPY EACH OF THE PATERNALANDOFTHEMATERNALALLELES(ENCETHEIRGAINOFSUSCEPTIBILITYFOR INFECTIONISINCOMPATIBLEWITHTHEPRESENCEOFADOMINANTLYACTINGPATERNALLY INHERITEDRESTRICTIONFACTORYETCOMPATIBLEWITHTHEPRESENCEOFAFUNCTIONAL PERMISSIVITY FACTOR ENCODED BY A MATERNAL GENE4HE NATURE OF THIS FACTOR ISCURRENTLYUNCLEARBUTDIFFERENTIALCLONINGORSIMILARTECHNIQUESMIGHTBE SUITEDFORITSIDENTIFICATION!LSO THESERESULTSDONOTRULEOUTTHATRESTRICTION FACTORSPLAYANIMPORTANTROLEINOTHERHEPADNAVIRUS HOSTSYSTEMS

#ONCLUSIONSANDOUTLOOK -ANYASPECTSOFHEPADNAVIRALREPLICATIONHAVEBEENELUCIDATEDINCONSID ERABLE DETAIL HOWEVER OUR UNDERSTANDING OF HEPADNAVIRUS HOST RANGE AND ITS MOLECULAR BASIS LAGS FAR BEHIND #ERTAINLY HEPADNAVIRUSES DO NOT HAVE ABROADHOSTRANGEYETWHETHERTHEIRHOSTRANGEISTRULYNARROWREMAINSA MATTEROFINTERPRETATIONASLONGASTHEPHYLOGENETICRELATIONSBETWEENTHE PROVEN HEPADNAVIRUS HOST SPECIES ARE NOT RIGIDLY DEFINED 5NFORTUNATELY HEPADNAVIRALHOSTRANGEISSUFFICIENTLYRESTRICTEDSOASTOLIMITINVIVOSTUDIES TOFEWEXPERIMENTALLYACCESSIBLESPECIESEVENFOR$("6THEFULLSPECTRUM OFINFECTABLEHOSTSISUNKNOWN)NVITROINFECTIONASSAYSALLOWACCESSTOCELLS FROMAWIDERRANGEOFHOSTSYETRECENTDATABOTHFORORTHOHEPADNAVIRUSES USING HUMAN AND7OOLLY MONKEY ("6 AND FOR AVIHEPADNAVIRUSES USING DUCKANDHERON("6 CASTDOUBTSONTHETRANSFERABILITYOFINVITRODATAON STATEMENTSONINVIVOHOSTRANGE/NEOFTHEMAJORCHALLENGES ASMENTIONED YEARS AGO ;= REMAINS THE UNAMBIGUOUS IDENTIFICATION OF THE CELLULAR RECEPTORS MEDIATINGPRODUCTIVEHEPADNAVIRUSINFECTIONCARBOXYPEPTIDASE



+AI$ALLMEIERAND-ICHAEL.ASSAL

$ THOUGHLIKELYINVOLVEDIN$("6INFECTION DOESNOTEXPLAINTISSUE AND HOSTTROPISM ANDDOESNOTATALLSEEMTOPLAYAROLEFORHUMAN("6INFEC TION 'IVEN THE LIMITED SUCCESS OF CONVENTIONAL APPROACHES IT IS HOPED THAT APPLICATION OF NEW TECHNIQUES SUCH AS EXPRESSION PROFILING AND GENE KNOCK DOWN BY 2.! INTERFERENCE TO PERMISSIVE VERSUS NON PERMISSIVE CELLSWILLHELPANSWERINGTHISQUESTIONHOWEVER THEPOTENTIALLYCRUCIALROLES OFNON PROTEINACEOUSMOLECULESASWELLASOFHOSTRESTRICTIONFACTORSMUST NOTBEDISREGARDED ANDSIMILARLY VIRALFACTORSOTHERTHAN0RE3COULDIMPOR TANTLYCONTRIBUTETOHEPADNAVIRALHOSTRANGE(ENCEBOTHSYSTEMATICWORK ANDIMAGINATIVETHINKINGWILLBEREQUIREDTOSOLVETHISENIGMATICASPECTOF HEPADNAVIRUS BIOLOGY AND REALISE THE MEDICALLY HIGHLY RELEVANT ISSUE OF A SMALLANIMALMODELFORHUMAN("6INFECTION

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DETERMINANT THAT CONTRIBUTES TO THE SPECIES SPECIFICITY OF HUMAN HEPATITIS " VIRUS*6IROLn 5RBAN 3 'RIPON 0  )NHIBITION OF DUCK HEPATITIS " VIRUS INFECTION BY A MYRISTOYLATED PRE 3 PEPTIDE OF THE LARGE VIRAL SURFACE PROTEIN * 6IROL  n .ASSAL- $ALLMEIER+ 3CHULTZ5 3UN$ 0HENOTYPINGHEPATITIS"VIRUS VARIANTS FROM TRANSFECTION TOWARDS A SMALL ANIMAL IN VIVO INFECTION MODEL * #LIN6IROL3UPPL3n 5RBAN 3 3CHWARZ # -ARX 5# :ENTGRAF ( 3CHALLER ( -ULTHAUP '  2ECEPTORRECOGNITIONBYAHEPATITIS"VIRUSREVEALSANOVELMODEOFHIGHAFFIN ITYVIRUS RECEPTORINTERACTION%-"/*n .ASSAL- 3CHALLER( (EPATITIS"VIRUSREPLICATION4RENDS-ICROBIOL n

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4HELIVERASIMMUNEESCAPESITEFORPATHOGENS 0ERCY!+NOLLEAND$IRK3TABENOW )NSTITUTEOF-OLECULAR-EDICINEAND%XPERIMENTAL)MMUNOLOGY 5NIVERSITY(OSPITAL"ONN &RIEDRICH 7ILHELM 5NIVERSITY"ONN 3IGMUND &REUD 3TR "ONN 'ERMANY

!BSTRACT "ESIDESITSIMPORTANTFUNCTIONFORPROTEIN LIPIDANDGLUCOSEMETABOLISMTHELIVEREXERTS SCAVENGERFUNCTIONINORDERTOCLEARTHEBLOODFROMDEGRADATIONPRODUCTS)TISBECOM INGINCREASINGLYCLEARTHATTHISSCAVENGERFUNCTIONISCLOSELYLINKEDTOTHELIVERSIMMUNE FUNCTION WHICH FAVOURS INDUCTION OF IMMUNE TOLERANCE RATHER THAN IMMUNITY4HE CELL POPULATION MOST ACTIVELY INVOLVED IN SCAVENGING OF BLOOD BORNE MACROMOLECULES IS AN ORGAN RESIDENTCELLPOPULATION THELIVERSINUSOIDALENDOTHELIALCELLS,3%# ,3%#ALSO HAVE PROMINENT IMMUNE REGULATORY FUNCTION AS THEY BEAR THE CAPACITY TO PRIME NAIVE #$AND#$4 CELLSAFTERPRESENTATIONOFEXOGENOUSANTIGENSON-(##LASS))OR-(# #LASS)MOLECULES RESPECTIVELY4HEOUTCOMEOFSUCH4 CELLPRIMINGBYANTIGEN PRESENT ING ,3%# IS INDUCTION OF4 CELL TOLERANCE (ERE WE ALSO DISCUSS THE OTHER MECHANISMS AND CELL POPULATIONS INVOLVED IN MEDIATION OF HEPATIC IMMUNE TOLERANCE7E DESCRIBE THEMECHANISMSOFHOWAVIRUSMAYGETACROSSCELLBARRIERS INPARTICULARTHEENDOTHELIAL CELLBARRIER)MPORTANTLY BLOOD BORNEVIRUSISSCAVENGEDBY,3%#(EREWEDISCUSSTHE EXPERIMENTALEVIDENCEINTHELITERATURETHATVIRUSUPTAKEBY,3%#DOESNOTNECESSARILY LEADTOLYSOSOMALDESTRUCTIONBUTRATHERRESULTSINTRANSCYTOTICTRANSPORTOFTHEVIRUSTO HEPATOCYTES4HUS ,3%# MAY PLAY A PIVOTAL ROLE IN HEPATOCELLULAR INFECTION BY BLOOD BORNEVIRUSI RETRIEVALFROMTHEBLOODSTREAMANDTRANSCYTOTICTRANSPORTFORINFECTIONOF THETARGETCELL THEHEPATOCYTE ANDII PREVENTIONOFVIRUS SPECIFIC#$4 CELLIMMUNITY BYSKEWINGANTIGEN SPECIFIC4 CELLRESPONSESBYPRESENTATIONOFVIRALANTIGENSATTHEVERY EARLYSTAGEOFINFECTION

)NTRODUCTION 4HELIVERASANORGANFULFILSMANYDIFFERENTTASKSTHATINCLUDEPROTEINAND LIPID METABOLISM CLEARANCE FUNCTION FOR REMOVAL OF TOXIC WASTE PRODUCTS FROM THE BLOOD CIRCULATION AND A PROMINENT IMMUNE REGULATORY FUNCTION 4HESE DIVERSE FUNCTIONS ARE PERFORMED BY COOPERATIVE ACTION OF DIFFERENT CELL POPULATIONS IN THE LIVER THAT ARE EITHER ORGAN RESIDENT OR ARE DERIVED FROM THE BONE MARROW FOLLOWED BY FUNCTIONAL ADAPTATION THROUGH INTER ACTION WITH THE UNIQUE HEPATIC MICROENVIRONMENT -OREOVER THE UNIQUE MICROANATOMYALSOCONTRIBUTESTOTHESEHEPATICFUNCTIONS



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4HEHEPATICMICROANATOMYANDCELLPOPULATIONS (EPATOCYTESFORMTHEMOSTPROMINENTHEPATICCELLPOPULATION WHICHCONSTI TUTESAPPROXIMATELYnOFLIVERCELLS;=(EPATOCYTESHAVEEXTRAORDI NARYMETABOLICFUNCTIONFORPROTEINLIPIDMETABOLISMANDFORDEGRADATION DISPOSALOFTOXICMATERIALVIATHEBILE4HUS HEPATOCYTESAREOFTENREGARDED AS THE CELL POPULATION THAT DETERMINES LIVER FUNCTION 4HIS ASSUMPTION IS SUPPORTEDBYTHECLINICALOBSERVATIONSTHATLOSSOFMORETHANOFHEPA TOCYTES EITHERDURINGACUTEDISEASESUCHASTOXICLIVERDAMAGEORFULMINANT VIRALHEPATITISORASACONSEQUENCEOFCHRONICINFLAMMATORYDISEASELEADING TOCIRRHOSIS ISFOLLOWEDBYTHEDEVELOPMENTOFLIVERFAILURE(OWEVER FROM THESEOBSERVATIONSITCANNOTBECONCLUDEDTHATOTHERCELLPOPULATIONSDONOT CONTRIBUTETOTHEFUNCTIONALREPERTOIREOFTHELIVER (EPATOCYTES TIGHTLY INTERACT WITH NEIGHBOURING HEPATOCYTES VIA THEIR APICALSURFACE WHICHENCLOSESTHEBILECANALICULI4HECELLSAREARRANGEDINA SANDWICHFORMATWITHTHEIRBASOLATERALSIDEFACINGTHESINUSOIDALENDOTHE LIUM-ICROVILLIPROTRUDEFROMTHEBASOLATERALSURFACEOFTHEHEPATOCYTESTO INCREASETHESURFACEANDALLOWFOREFFICIENTUPTAKEANDRELEASEOFMATERIALS BETWEEN HEPATOCYTE AND BLOOD "ECAUSE OF THE METABOLIC FUNCTION MORE THAN  OF CARDIAC BLOOD OUTPUT PASSES THROUGH THE LIVER IN A UNIQUE MIXED ARTERIO VENOUS CIRCULATION .UTRIENT RICH BLOOD FROM THE INTESTINAL TRACTREACHESTHELIVERVIATHEPORTALVEINTHATBRANCHESINTOSMALLVENULES ENTERINGTHEPARENCHYMALAREAINTHEPORTALTRACTTOGETHERWITHABRANCHOF THE HEPATIC ARTERY!RTERIAL AND VENOUS VESSELS MERGE IN THE HEPATIC SINU SOIDS THAT ARE LINED BY THE SPECIALISED SINUSOIDAL ENDOTHELIAL CELLS OF THE LIVER"LOODFLOWINTHELIVERISSLOWn+MS ASARESULTOFTHEENOR MOUS CUMULATIVE SINUSOIDAL VESSEL DIAMETER AND THE MIXED ARTERIOVENOUS CIRCULATIONTHATRESULTSINALOW PRESSUREPERFUSIONPROFILE;="LOODPERCO LATESTHROUGHTHEHEPATICSINUSOIDSTOREACHTHECENTRALVEINTHATDRAINSINTO THEINFERIORVENACAVA +UPFFER CELLS CONSTITUTE THE HEPATIC MACROPHAGE POPULATION 4HEY ARE DERIVED FROM THE BONE MARROW AND SHOW CONSIDERABLE HALF LIFE IN THE TIS SUE+UPFFERCELLSAREARICHSOURCEOFSOLUBLEMEDIATORSSUCHASPROSTANOIDS CYTOKINESANDCHEMOKINES;=THATARENOTONLYOPERATIVEINLOCALIMMUNE REGULATION DISCUSSED BELOW BUT ALSO ENHANCE HEPATOCELLULAR EXPRESSION OFACUTEPHASEPROTEINSTHROUGHRELEASEOF), AND), ; =-OREOVER +UPFFER CELLS HAVE POTENT PHAGOCYTIC ACTIVITY AND ELIMINATE OPSONISED MICROORGANISMS AS WELL AS CELLULAR DEBRIS ;= 4HE MACROPHAGES PATROL THROUGH HEPATIC SINUSOIDS EVEN AGAINST THE BLOODSTREAM AND THUS CAUSE TURBULENCEOFBLOODFLOW&IG ;=(OWEVER MOST+UPFFERCELLSAREFOUND INTHEPERIPORTALAREA WHERETHEBLOODENTERSTHELIVER ,IVERSINUSOIDALENDOTHELIALCELLS,3%# LINETHEHEPATICSINUSOIDSFROM THEPORTALTRACTTOTHECENTRALVEIN;=,3%#NOTONLYSERVEASAPLATFORM FOR MIGRATING +UPFFER CELLS OR LIVER ASSOCIATED LYMPHOCYTES SEE BELOW BUTALSOMARKTHESPACEOF$ISSÏTHATISSITUATEDBETWEENTHEHEPATOCYTES

The liver as immune escape site for pathogens

343

Figure 1. Schematic demonstration of a hepatic sinusoid. The lumen of the sinusoidal blood vessel is lined by liver sinusoidal endothelial cells. Liver-associated lymphocytes (LAL), a heterogeneous population of NK, NKT and T-cells, as well as bone marrow-derived liver resident macrophages, Kupffer cells, reside within the lumen of the sinusoids. LSEC physically separate cells and molecules circulating with the blood from hepatocytes. The area between hepatocytes and LSEC is called the space of Dissé. Stellate cells are located inside the space of Dissé giving them the possibility to control the diameter of the sinusoid.

and LSEC (Fig. 1). Due to the small sinusoidal diameter (7–10 μm) leukocytes and red blood cells that pass through the vessels cause a sinusoidal ‘massage’ or ‘forced sieving’ that increases fluid exchange between the sinusoidal lumen and the space of Dissé [9]. In contrast to microvascular endothelial cells in most other tissues, LSEC have fenestrations that allow for fluid exchange to occur between the blood and hepatocytes. The size of fenestrae is dynamically regulated and allows for passage of chylomicrons into the space of Dissé [10]. There is no basal membrane and tight junctions between adjacent LSEC are lacking. Although hepatocellular microvilli can protrude through endothelial fenestrae, the cumulative surface of LSEC is



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MUCHLARGERASCOMPAREDTOHEPATOCYTEMICROVILLI,3%#AREORGAN RESIDENT CELLSTHATREPOPULATESIMILARTOHEPATOCYTESFROMASOFARILL DEFINEDHEPATIC PRECURSORCELLPOPULATION;= 3TELLATE CELLS ARE SITUATED BETWEEN HEPATOCYTES AND ,3%# WITHIN THE SPACE OF $ISSÏ &IG  ;=4HESE CELLS ARE THE MAJOR STORAGE SITE FOR RETI NOIDS INCLUDINGVITAMIN! ANDPOSSESSLARGENUMBERSOFMICROTUBULESAND MICROFILAMENTS 3TELLATE CELLS ARE INVOLVED IN REGULATION OF BLOOD FLOW BY ACTIVELYCONTROLLINGTHESINUSOIDALDIAMETERINRESPONSETOVASODILATORYOR VASOCONSTRICTORY SIGNALS ;= -OREOVER STELLATE CELLS ARE A RICH SOURCE OF CHEMOKINESANDCYTOKINES4HEYAREMOSTIMPORTANTDURINGDEVELOPMENTOF HEPATICFIBROSISBECAUSEINFLAMMATIONORINJURYCAUSESSTELLATECELLACTIVATION THAT RESULTS IN PREDOMINANT DEPOSITION OF EXTRACELLULAR MATRIX RATHER THAN DEGRADATION;=3TELLATECELLSAREINCLOSEINTERACTIONWITHHEPATOCYTESAND ,3%#ONEITHERSIDEANDAREINCLOSEASSOCIATIONWITHNERVEFIBERS;= ,IVERASSOCIATEDLYMPHOCYTESHAVEORIGINALLYBEENDEFINEDBYTHEIRCHAR ACTERISTIC MICROSCOPIC APPEARANCE BUT CONSIST OF A RATHER HETEROGENEOUS POPULATION OF .+ CELLS 4 CELLS AND .+4 CELLS ;=4HESE CELL POPULATIONS AREABUNDANTINTHELIVERWITHMORETHANLYMPHOCYTESBEINGFOUNDIN HUMANLIVER%XPRESSIONOFCERTAINCHEMOKINESANDADHESIONMOLECULESBY ORGAN RESIDENT LIVER CELLS AND EXPRESSION OF APPROPRIATE HOMING RECEPTORS ALLOW THESE CELLS TO ACCUMULATE IN THE LIVER ;=4HESE CELLS ALSO MIGRATE THROUGH HEPATIC SINUSOIDS ;=4HE HETEROGENEITY OF HEPATIC LYMPHOCYTES INDICATESTHATTHESECELLSCONTRIBUTEINACOMPLEXFASHIONTOLOCALIMMUNE REGULATIONINTHELIVER )NTHEPORTALTRACTSFURTHERCELLPOPULATIONSAREFOUNDSUCHASBILEDUCT CELLS PORTALFIBROBLASTSANDDENDRITICCELLS4HEPORTALTRACTAPPEARSTOBEA DISTINCTFUNCTIONALCOMPARTMENTOFTHELIVERSERVINGASENTRYPORTALFORARTE RIALANDVENOUSBLOODASWELLASEXITPORTALFORHEPATICBILE4HECELLULARAND MOLECULARMECHANISMSSUPPORTINGTHEVARIOUSREQUIREMENTSTOALLOWTHESE FUNCTIONALPROPERTIESARELARGELYUNKNOWN

4HELIVERASTARGETORGANFORPATHOGENS "LOOD BORNEPATHOGENSTHATCIRCULATEWITHTHEBLOODSTREAMAREELIMINATED MAINLY IN TWO ORGAN SYSTEMS IE THE SPLEEN AND THE LIVER 7HILE MACRO PHAGES IN THE MARGINAL ZONE ARE RESPONSIBLE FOR ELIMINATION OF BACTERIAL PATHOGENS IN THE SPLEEN +UPFFER CELLS AS WELL AS PLATELETS AND NEUTROPHILS WITHINHEPATICSINUSOIDSCOOPERATETOACHIEVECLEARANCEOFCIRCULATINGBAC TERIA IN THE LIVER ; = -ECHANISTICALLY INTRAVASCULAR NEUTROPHIL ACTIVA TIONRESULTINGFROMBINDINGOFPLATELETSACTIVATEDBYBACTERIAL4,2 LIGANDS LEADS TO FORMATION OF NEUTROPHIL EXTRACELLULAR TRAPS 4HESE TRAPS ENSNARE BACTERIAWITHINTHEVASCULATUREOFTHELIVERBUTALSOOFTHELUNGANDPROMOTE BACTERIALTRAPPINGANDPHAGOCYTICELIMINATION;=4HUS THELIVERSERVESAS AFILTERSYSTEMTOELIMINATECIRCULATINGBACTERIAFROMTHEBLOOD#ENTRALTO

4HELIVERASIMMUNEESCAPESITEFORPATHOGENS



THIS ANTIBACTERIAL ACTIVITY IS THE CONSTITUTIVE EXPRESSION OF INNATE IMMUNE RECEPTORS SUCH AS THE4OLL LIKE RECEPTORS ON VARIOUS LIVER CELL POPULATIONS THAT ALLOWS SENSING OF BACTERIAL PATHOGENS AND APPROPRIATE CELL ACTIVATION ;=!NTI BACTERIALDEFENSEINTHELIVERAPPARENTLYWORKSEFFICIENTLY BECAUSE THEREAREFEWCLINICALEXAMPLESFORPERSISTENTBACTERIALINFECTIONSOFTHELIVER WHICHAREDEALTWITHELSEWHEREINTHISBOOK 6IRAL INFECTION OF THE LIVER HOWEVER REPRESENTS A SIGNIFICANT PROBLEM ANDMANYHUNDREDMILLIONSOFPATIENTSPERSISTENTLYINFECTEDWITHHEPATITIS " OR HEPATITIS # VIRUS SUFFER FROM THE CONSEQUENCES OF IMMUNE MEDIATED CHRONIC VIRAL HEPATITIS &OR DISTRIBUTION WITHIN A POPULATION HEPATOTROPIC VIRUSES HAVE TO CROSS DIFFERENT BARRIERS IN ORDER TO ACHIEVE INFECTION OF A NEWHOST4HEFIRSTBARRIERENCOUNTEREDISTHESKINORMUCOSALSURFACESTHAT BLOCK ENTRY INTO THE BODY %VEN IF THIS BARRIER IS OVERCOME BLOOD BORNE VIRUSAGAINHASTOCROSSBARRIERSSUCHASENDOTHELIALSURFACESCELLLAYERSTO REACHTHEIRTARGETCELLS WHICHARETHEPARENCHYMALCELLSOFTHELIVER)NPRIN CIPLE FORAVIRUSTOCROSSAPHYSICALBARRIEROFEPITHELIALORENDOTHELIALCELLS REQUIRESEITHERA@4ROJANHORSESTRATEGYORUTILISATIONOFCELLULARTRANSPORT MACHINESWITHPOLARORIENTATION"OTH THE@4ROJANHORSESTRATEGYASWELLAS TRANSCYTOSISHAVEBEENREPORTEDTOBEEMPLOYEDBYVIRUSES SUCHAS()6 TO ACHIEVEINFECTIONOFNEWHOSTS; = (EPATOTROPIC VIRUSES LIKE HEPATITIS ! VIRUS (!6 HEPATITIS " VIRUS ("6 AND HEPATITIS # VIRUS (#6 ALSO HAVE TO CROSS EPITHELIAL BARRIERS ANDTHELIVERSINUSOIDALENDOTHELIALCELLLAYER WHICHSEPARATESTHEHEPATO CYTESFROMTHEBLOOD TOFINALLYINFECTTHEIRTARGETCELLS THEHEPATOCYTES6ERY LITTLEISKNOWNONTHEMECHANISMSTHATALLOWTHESEVIRUSESTOCROSSEPITHELIAL BARRIERSINTHEGASTROINTESTINALORUROGENITALTRACT;=!LSOAFTERDISSEMI NATIONINTOTHEBLOODSTREAM THEMECHANISMSTHATALLOWEFFICIENTTARGETING OFHEPATOCYTESHAVENOTBEENCLEARLYUNRAVELLED&URTHERMORE ,3%#HAVE SOMEUNIQUEFEATURESTHATCOMPLICATEHEPATOCELLULARINFECTIONFORABLOOD BORNEVIRUS 4HEFIRSTOBSTACLEISTHEPHYSICALBARRIERFORMEDBY,3%#,3%#SEPARATE HEPATOCYTESFROMLEUKOCYTESPASSINGWITHINTHEBLOODTHROUGHTHELIVER;= )THASBEENOBSERVEDTHATHEPATOCYTEMICROVILLIPROTRUDEINTOTHESINUSOIDAL LUMENALLOWINGFORDIRECTCONTACTWITHBLOOD BORNECELLSORPATHOGENS;= "UTTHEOVERALLSURFACEAREAOF,3%#COMPAREDTOPENETRATINGHEPATOCYTE MICROVILLIISMUCHMOREPROMINENT(OWEVER ,3%#HAVEFENESTRAE WHICH AREORGANISEDINTOSIEVEPLATES ANDTHEMEANSIZEOFTHESEFENESTRAE RANG INGBETWEENANDNM ISDYNAMICALLYREGULATED;=&ENESTRAEWOULD PROVIDEADIRECTPORTALOFENTRYFORBLOOD BORNEVIRUSESTOTHEPARENCHYMA )THASBEENPROPOSEDEARLIERFOR0LASMODIUMBERGHEI THATSPOROZOITESINFECT HEPATOCYTESDIRECLYTHROUGHFENESTRAE;= BUTTHISHASNOTBEENCONFIRMED BY OTHER SCIENTISTS IN THE FIELD RATHER SPOROZOITE TARGETING OF THE LIVER INVOLVESINITIALINFECTIONOF+UPFFERCELLS;=ANDTRANSIENTINFECTIONOFMUL TIPLE HEPATOCYTES BY A SINGLE SPOROZOITE BEFORE PRODUCTIVE HEPATOCELLULAR INFECTIONISFINALLYACHIEVED;=(EPATOTROPICVIRUSESCOULDALSOGAINACCESS



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TOTHESPACEOF$ISSÏBYDIFFUSIONTHROUGHENDOTHELIALFENESTRAE"UTASTHE SPACEOF$ISSÏISFILLEDWITHEXTRACELLULARMATRIX WHICHISNOTREADILYVISIBLE INELECTRONMICROSCOPY PASSIVEDIFFUSIONOFPARTICLESLARGERTHANNMINTO THESPACEOF$ISSÏANDUPTAKEBYHEPATOCYTESDOESNOTOCCURWITHHIGHEFFI CIENCY;=)TISTHEREFOREREASONABLETOASSUMETHATHEPATOTROPICVIRUSES WHICHALLEXCEEDNMINDIAMETER DONOTHAVEDIRECTACCESSTOHEPATOCEL LULARMICROVILLIINTHESPACEOF$ISSÏ)TISALSOUNLIKELYTHATINTHECASEOF VIRUSENTRYTHROUGHFENESTRAEPASSIVEDIFFUSIONWOULDSUFFICETOBRIDGETHE DISTANCETOTHEHEPATOCYTEWITHINTHEEXTRACELLULARMATRIX 4HESECONDOBSTACLEPOSEDBY,3%#ISTHEIRENORMOUSSCAVENGERACTIVITY ;="LOOD BORNEMOLECULESARESCAVENGEDMOSTEFFICIENTLYANDALSOBLOOD BORNE HEPA$.! VIRUS IS FOUND WITHIN MINUTES AFTER INTRAVENOUS APPLICA TIONINTHELIVERWITHIN,3%# BUTNOTINOTHERHEPATICCELLPOPULATIONS;= )NTERESTINGLY +UPFFER CELLS DO NOT CONTRIBUTE TO THE SAME EXTENT AS ,3%# TOSCAVENGINGOFSMALLMOLECULESORPATHOGENSFROMTHEBLOODSTREAM;= 'IVEN THE LOW DOSE INFECTION PARADIGM FOR HEPA$.! VIRUSES WHERE ONE VIRUSISSUFFICIENTTOESTABLISHHEPATOCELLULARINFECTION;=AND37IEHLAND PERSONAL COMMUNICATION  4HESE EXPERIMENTAL RESULTS RATHER SUPPORT THE NOTION THAT HEPA$.! VIRUSES INITIALLY TAKEN UP BY ,3%# STILL HAVE THE POTENTIAL TO REACH AND INFECT NEIGHBOURING HEPATOCYTES THE ONLY CELL TYPE WHEREREPLICATIONOFTHISHEPATOTROPICVIRUSCANTAKEPLACE 4HE MOST LIKELY MOLECULAR MECHANISM FOR VIRUSES TO COME ACROSS THIS PHYSICALANDFUNCTIONALCELLBARRIERISTRANSCYTOSIS4RANSCYTOSISISACOMMON MECHANISMFORMACROMOLECULESTOOVERCOMETIGHTCELLLAYERS)TISDIVIDED INTOENDOCYTOSIS TRANSPORTACROSSTHECELLANDEXOCYTOSIS4HEBEST STUDIED EXAMPLESARETRANSCYTOSISOF)G!INPOLARISEDEPITHELIALCELLSANDTHETRANS CYTOSISOFMACROMOLECULESTHROUGHENDOTHELIUM

2ECEPTOR MEDIATEDTRANSCYTOSIS )MMUNGLOBULIN!)G! ISSYNTHESISEDBYPLASMACELLSINTHELAMINAPROPRIA OFTHEDIGESTIVE UROGENITALANDRESPIRATORYTRACT"UT)G!EXERTSITSFUNCTION ONTHELUMINALSIDEOFTHEMUCOSAINDICATINGTHATTRANSPORTOF)G!THROUGH EPITHELIAL CELLS IS REQUIRED 4HE TRANS CELLULAR TRANSPORT OF DIMERIC )G! D)G! WITH ITS RECEPTOR POLYMERIC IMMUNOGLOBULIN RECEPTOR P)G2 WAS EXTENSIVELYSTUDIEDINPOLARISED-ADIN $ARBYCANINEKIDNEYCELLS-$#+ RATLIVERHEPATOCYTESANDHEPATOCYTECELLLINESD)G!BINDSONTHEBASOLATERAL SURFACETOITSRECEPTORP)G2ANDTHERESULTINGCOMPLEX BUTALSOTHEEMPTY P)G2 AND IS THEN ENDOCYTOSED VIA CLATHRIN COATED PITS ;= /N THEIR WAY FROMTHEBASOLATERALTOAPICALCELLSURFACETHEP)G2TRAFFICSTHROUGHVARIOUS ENDOSOMALCOMPARTMENTS DEPENDINGONTHEMODELSYSTEM)N-$#+CELLS THE P)G2 TRAVELS THROUGH A BASOLATERAL EARLY ENDOSOME A COMMON ENDO SOME AND AN APICAL RECYCLING ENDOSOME !2% ;n= )N HEPATOCYTES THERE ARE ONLY TWO COMPARTMENTS THE BASOLATERAL EARLY ENDOSOME AND A

The liver as immune escape site for pathogens

347

Figure 2. The different mechanisms of transcytosis. Immunglobulins or immunglobin/antigencomplexes are transported through cells after binding to specific receptors (left). The pIgR transports dIgA molecules, produced in the lamina propria, across the epithelial cell layer in a basolateral to apical direction into the lumen. The reverse mechanism, the transport of IgA-Antigen complexes from the lumen (apical) to the basolateral side of the cell, is also possible, but to a lesser extent. For IgG, the receptor involved in transcytosis is FcRn, which can transport IgGs and IgG-Antigen-complexes in both directions. In the middle, the direct, receptor-independent transport of particles through caveolae is depicted. Furthermore, transport of virus can occur independent of transcytosis through transinfection. Thereby a cell, which is not infected by the virus, transports virus bound to its surface across cell layers. After transmigration the cell mediates infection in trans of the target cells, where the virus then replicates (right).

subapical compartment (SAC) [35, 36]. After exit from the ARE/SAC, pIgR is transported to the apical plasma membrane. During this transport or at the plasma membrane pIgR is cleaved at the extracellular domain and this cleaved part is called the secretory component (SC) [37]. dIgA which has been bound to pIgR and is now in complex with cleaved SC is called secretory IgA (sIgA) (Fig. 2). Binding of luminal IgA to virus and subsequently to pIgR on mucosal surfaces may therefore allow virus to cross the epithelial barrier. As mentioned above pIgR is endocytosed at the basolateral side irrespective if dIgA is bound or not. Transcytosis of ‘empty’ pIgR may thus allow for binding of luminal IgA to occur at the apical plasma membrane. This is possible because, at least in the MDCK model, pIgR molecules are not completely cleaved. IgA bound to pIgR at the apical plasma membrane has been shown to be transcytosed in a retrograde fashion and to be released at the basolateral side [38]. This empty pIgR can also bind HAV-IgA complexes on the apical side and transcytoses it back to the basolateral side where HAV-IgA complexes are released (Fig. 2). Such HAV-IgA complexes are shown to



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BE INFECTIOUS FOR HEPATOCYTES ;= (OWEVER THIS RETROGRADE TRANSCYTOTIC TRANSPORTAPPEARSUNLIKELYTOBEEFFICIENTFORVIRUSTRANSCYTOSIS BECAUSETHE PRESENCEOFVIRUS SPECIFIC)G!LEADSTOINTRACELLULARVIRUSNEUTRALISATIONDUR INGTHEPROCESSOFTRANSCYTOSIS;= !SECONDRECEPTORINVOLVEDINTRANSCYTOTICTRANSPORTISALSOSPECIFICFOR )G IE &C2N &C2N IS EXPRESSED IN VARIOUS TISSUES NAMELY THE PLACENTA WHERE IT ALLOWS SELECTIVE DELIVERY OF )G' FROM THE MATERNAL TO THE FETAL BLOOD CIRCULATION AND ALSO IN THE ENDOTHELIUM OF SMALL BLOOD VESSELS AND BINDS)G'S;=)NINTESTINALEPITHELIALCELLSASWELLASCULTUREDINTESTINAL4 CELLS )G'SARETRANSCYTOSEDINBOTHDIRECTIONSBY&C2N&IG ; =4HIS INDICATESANEWROLEFORTHENEONATAL&C2N NAMELYTRANSPORTOF)G'FROM THEBASALSIDETOAPICALSIDEOFTHECELLANDSUBSEQUENTSECRETION!FTERANTI GEN BINDING )G' ANTIGEN COMPLEXES ARE BOUND BY &C2N AND TRANSCYTOSED INTHEOPPOSITEDIRECTIONDELIVERINGTHECOMPLEXESOUTOFTHELUMENTOTHE LAMINAPROPRIAWHEREIMMUNERESPONSESAGAINSTLUMINALANTIGENSTHENCAN TAKE PLACE ;= ,3%# ALSO EXPRESS &C2N AND IT IS TEMPTING TO SPECULATE THAT HEPATOTROPIC VIRUSES COMPLEXED BY )G' WOULD BIND TO &C2N WHICH THENWOULDALLOWTRANSCELLULARTRANSPORTTOWARDSTHESPACEOF$ISSÏ3TILL IT ISUNCLEARWHETHER)G COMPLEXEDVIRUSWOULDBESUBJECTEDTOINTRACELLULAR NEUTRALISATION SIMILAR TO THE OBSERVATION FOR )G! MEDIATED NEUTRALISATION OF()6;= )THASALSOBEENSHOWNTHATRECEPTOR MEDIATEDTRANSCYTOSISFROMANON IMMUNGLOBULINRECEPTORCANLEADTOATRANSPORTOFMACROMOLECULESPARTICLES ACROSSACELLLAYER-ANNAN COATEDGOLDPARTICLESOFNMSIZE COMPARABLE INSIZETOSOMEVIRUSES INJECTEDINTOTHETAILVEINOFRATSARERAPIDLYTAKEN UPBYENDOTHELIALCELLSINTHELIVER4HEMANNAN COATEDGOLDPARTICLESACCU MULATEDINCOATEDPITSONTHEPLASMAMEMBRANEONENDOTHELIALCELLSn H AFTER INJECTION THE GOLD PARTICLES ARE FOUND NEAR THE BASOLATERAL SIDE OF ,3%#NEXTTOTHESPACEOF$ISSÏANDLATERONTHEYAREALSOFOUNDINTHEADJA CENT HEPATOCYTES ;= INDICATING TRANSCYTOTIC TRANSPORT OF MANNAN COATED PARTICLESANDDELIVERYINTONEIGHBOURINGHEPATOCYTES .OTONLYGOLDPARTICLESMAYBESUBJECTTOTRANSCYTOTICTRANSPORTTHROUGH ,3%# )T HAS BEEN SUGGESTED THAT BLOOD BORNE HEPATOTROPIC VIRUSES IN PARTICULAR DUCK HEPATITIS " VIRUS $("6 ARE TRANSCYTOSED THROUGH THE LIVER SINUSOIDAL ENDOTHELIUM "REINER ET AL HAS SHOWN THAT FLUORESCENTLY LABELLEDVIRALPARTICLESANDGOLD LABELLED$("6PARTICLESARERAPIDLYTAKEN UPBY,3%#;=#ONFOCALLASERSCANNINGMICROSCOPYANALYSISREVEALEDTHAT FLUORESCENTLY LABELLED VIRAL PARTICLES COLOCALISED WITH THE $("6 RECEPTOR CARBOXYPEPTIDASE$ INTHETRANS 'OLGICOMPARTMENT THEREBYRESCUINGVIRUS PARTICLES FROM LYSOSOMAL DEGRADATION !LTHOUGH RAPID UPTAKE OF $("6 WASOBSERVEDINTO,3%# THEREWASNOVIRALGENEEXPRESSIONORFORMATION OFVIRALPROGENY;=7EASSUMEDTHAT$("6PARTICLESWERETRANSCYTOSED THROUGH ,3%# FOLLOWING RAPID INITIAL UPTAKE AND THAT ABSENCE OF ,3%# INFECTION WOULD ALLOW TRANSCYTOSED $("6 TO BE AVAILABLE FOR SUBSEQUENT INFECTION OF NEIGHBOURING HEPATOCYTES ;= 3UCH A MODEL WOULD NOT ONLY

4HELIVERASIMMUNEESCAPESITEFORPATHOGENS



EXPLAIN THE PARADOX THAT THE VAST MAJORITY OF VIRUS PARTICLES IS TAKEN UP PREFERENTIALLYBYSCAVENGER,3%#ANDNOTBYHEPATOCYTESBUTSTILLALLOWSFOR SMALLNUMBERSOFVIRUSESTOESTABLISHPRODUCTIVEHEPATOCELLULARINFECTION)T WOULDALSOPROVIDEANEXPLANATIONTOTHEQUESTIONHOWHEPATOTROPICVIRUSES REACHTHELIVER BECAUSETHESCAVENGERFUNCTIONOF,3%#WOULDTARGETTHE VIRUSTOTHELIVER

2ECEPTOR INDEPENDENTTRANSCYTOSIS 5PTAKEENDOCYTOSIS OF MACROMOLECULES CAN ALSO OCCUR IN A RECEPTOR INDEPENDENT WAY /N ENDOTHELIAL CELLS NEGATIVELY CHARGED MOLECULES ARE MOSTLYREJECTEDDUETOTHENEGATIVECHARGEOFTHEAPICALPLASMAMEMBRANE #LATHRIN COATEDPITSAREALSOMOSTLYNEGATIVELYCHARGEDLEADINGTOTHEFACT THAT CATIONIC MOLECULES PREFERENTIALLY BIND TO CLATHRIN COATED PITS AND ARE SUBSEQUENTLY DEGRADED IN LYSOSOMES ;= .EGATIVELY CHARGED MOLECULES WHICH ARE NOT ACCESSIBLE TO THIS PATHWAY ARE TAKEN UP BY PINOCYTOSIS AND SHUTTLED TO THE BASOLATERAL SIDE WHERE THEY ARE RELEASED4HIS TRANSCYTOTIC TRANSPORTISMOSTLYMEDIATEDTHROUGHCAVEOLAEBYCAVEOLIN&IG  )THASBEENSHOWNRECENTLYTHATCAVEOLINKNOCKOUTMICECANNOTTRANS PORTGOLD LABELLED"3!FROMTHELUMINALSIDEOFTHEVESSELTOTHEINTERSTI TIUM WHEREAS WILD TYPE MICE ARE CAPABLE OF TRANSCYTOSING THESE PARTICLES 'IVENTHESMALLSIZEOFSOMEVIRUSES WHICHISINSOMECASESCOMPARABLETO GOLDPARTICLES THISISALSOANATTRACTIVEMODELHOWVIRUSESCANCROSSENDOTHE LIALCELLSTOREACHTHEIRTARGETCELLSINTHETISSUE

)NFECTIONINTRANS 4RANSINFECTIONISACOMMONMECHANISMBYWHICHVIRUSESREACHTHEIRTARGET CELLS)NCONTRASTTOINFECTIONINCIS WHERETHEVIRUSDIRECTLYINFECTSITSTARGET CELL INFECTIONINTRANSDESCRIBESAMECHANISMWHERETHEVIRUSATTACHESFIRST TOACELL WHICHITSELFISNOTINFECTED BUTATLATERTIMEPOINTSMEDIATESINFEC TIONOFTHETARGETCELL3UCHA@4ROJANHORSESTRATEGYHASBEENSHOWNTOBE USED BY ()6 WHICH FIRST BINDS TO DENDRITIC CELLS IN SUBMUCOSAL TISSUE AND IS CARRIED BY DENDRITIC CELLS INTO THE DRAINING LYMPH NODE WHERE INFECTION OF THE #$4 CELLS OCCURS BY CLOSE INTERACTION OF $# SURFACE BOUND ()6 WITH#$4 CELLS;=)NTERESTINGLY ()6ISCAPTUREDBYA# TYPE))LECTIN $# 3)'. THATDOESNOTTARGET()6FORLYSOSOMALDESTRUCTIONUPONRECEP TOR MEDIATED ENDOCYTOSIS BUT ALLOWS FOR RE SHUTTLING OF ()6 $# 3)'. COMPLEXES TO THE CELL SURFACE 4HIS STEP FACILITATES INFECTION OF THE TARGET CELLSINTRANS!SIMILARMECHANISMFORVIRALPROPAGATIONHASBEENREPORTED FOR%"6;=4HISOPENSUPTHEPOSSIBILITYTHATHEPATOTROPICVIRUSESBOUND TOLEUKOCYTESTHATTRANSMIGRATEACROSSTHEENDOTHELIALBARRIERMAYACHIEVE ACCESSTOHEPATOCYTES&IG 



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(OWEVER $# 3)'.ISKNOWNTOBINDABROADVARIETYOFDIFFERENTVIRUSES ;n= AND $# 3)'. AS WELL AS ITS HOMOLOG $# 3)'.2 , 3)'. ARE FOUNDINTHELIVER;=2ECENTPUBLICATIONSSHOWTHAT, 3)'.ANDALSO$# 3)'.AREEXPRESSEDON,3%#ANDTHATTHESELECTINSARECAPABLEOFCAPTUR ING(#6PARTICLESWITHHIGHAFFINITY; =4HESEMOLECULESHOWEVERDO NOTPROMOTEENTRYOF(#6ANDSUBSEQUENTINFECTIONOF,3%#)NCONTRAST IT HASBEENSHOWNTHATLIVERSINUSOIDALENDOTHELIALCELLSPROMOTETHEUPTAKEOF (#6 LIKEPARTICLESINPRIMARYRATANDHUMANHEPATOCYTES;=(IGHLYPURI FIEDHEPATOCYTESINCULTUREDONOTTAKEUP(#6 LIKEPARTICLES WHEREASINCO CULTUREWITH,3%#UPTAKEOFVIRUSPARTICLESINTOHEPATOCYTESWASOBSERVED #OLLECTIVELY THESERESULTSSUGGESTTHENOTIONTHATVIRUSINTERNALISEDBY,3%# ISNOTDEGRADEDBUTISAVAILABLEATLATERTIMEPOINTSFORINFECTIONOFHEPATO CYTESINTRANS

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4HELIVERASIMMUNEESCAPESITEFORPATHOGENS



)NVESTIGATINGTHEIMMUNEREGULATORYFUNCTIONOFHEPATICCELLPOPULATIONS ONEHASTOCONSIDERTHATTHEABILITYTOPRESENTEXOGENOUSANTIGENSON-(# #LASS))OR-(##LASS)MOLECULESTO#$OR#$4 CELLS RESPECTIVELY IS RESTRICTEDTOPROFESSIONALANTIGENPRESENTINGCELLS IE MACROPHAGES "CELLS ANDDENDRITICCELLS/NLYTHESEIMMUNECELLPOPULATIONSAREEQUIPPEDWITH CO SIGNALLINGMOLECULESTHATDELIVERINADDITIONTO4 CELLRECEPTORSIGNALING FURTHER STIMULI THAT INFLUENCE THE QUALITY IMMUNITY OR TOLERANCE OF THE ENSUING4 CELLRESPONSE (EPATOCYTESEXPRESSLITTLE-(##LASS)ANDNO-(##LASS))MOLECULES AND BEAR THE ABILITY TO INITIATE #$ 4 CELL RESPONSES (OWEVER PRIMING OF NAIVE #$4 CELLS BY HEPATOCYTES LEADS TO INCOMPLETE4 CELL ACTIVATION AND FOLLOWING INITIAL PROLIFERATION 4 CELLS UNDERGO APOPTOSIS RESULTING IN CLONAL DELETION OF 4 CELLS RECOGNISING THEIR ANTIGEN ON HEPATOCYTES ;= )NTERESTINGLY LOCATION AND TIMING DURING THE INDUCTION OF AN IMMUNE RESPONSEDETERMINESALSOTHEQUALITYOFANIMMUNERESPONSE)FANTIGENIS FIRST RECOGNISED BY #$4 CELLS ON HEPATOCYTES IMMUNE TOLERANCE ENSUES EVENIFANTIGENRECOGNITIONOCCURSLATERONPROFESSIONALANTIGEN PRESENTING DENDRITICCELLSINLYMPHATICTISSUE)NCONTRAST IFANTIGENISFIRSTSEENONACTI VATEDDENDRITICCELLSINLYMPHATICTISSUEIMMUNITYDEVELOPS ANDSUBSEQUENT ANTIGENRECOGNITIONONHEPATOCYTESLEADSTODEVELOPMENTOFIMMUNE MEDI ATED HEPATITIS ;=4HESE RESULTS DEMONSTRATE THAT THE INITIAL ANTIGEN SPE CIFIC CONTACT OF NAIVE #$4 CELLS DETERMINES THE OUTCOME OF AN IMMUNE RESPONSE!SVIRUS INFECTEDHEPATOCYTESWILLPRESENTVIRALANTIGENSON-(# #LASS)MOLECULESTO#$4 CELLSITISTEMPTINGTOSPECULATETHATSUCHTOLERIS INGMECHANISMSMAYALSOBEOPERATIVEDURINGVIRALHEPATITIS 4HERE IS A CONTINUOUS DEBATE AS TO WHETHER THERE IS DIRECT CONTACT OF CIRCULATING#$4 CELLSWITH-(##LASS)MOLECULESONHEPATOCYTESACROSS STELLATECELLSAND,3%#5SINGULTRASTRUCTURALANALYSISITWASREPORTEDTHAT #$4 CELLS COULD PENETRATE WITH PODOSOMES THROUGH SINUSOIDAL FENESTRA TIONSANDESTABLISHDIRECT FOCALCONTACTSITESWITHHEPATOCYTES;=4HEINVA SIONOFENDOTHELIALCELLSWITHPODOSOMESINITIATESTRANSCELLULARDIAPEDESISOF 4 CELLS;= BUTITHASNOTBEENCONVINCINGLYSHOWNTHAT4 CELLSRECOGNISING THEIRANTIGENINTHELIVERNECESSARILYUNDERGOTRANSMIGRATIONINTOTHEHEPATIC PARENCHYMA (OWEVER RECOGNITION OF A UBIQUITOUSLY EXPRESSED ANTIGEN LEADS TO PREFERENTIAL ACCUMULATION OF #$4 CELLS IN THE LIVER WHICH SUP PORTS THE NOTION MENTIONED ABOVE THAT THE LIVER INITIATES4 CELL RESPONSES ;=#ONTROVERSIALRESULTSWEREOBTAINEDWHENUSINGDIFFERENTMOUSESTRAINS TO DETERMINE WHETHER #$4 CELLS CAN RECOGNISE THEIR ANTIGEN ON HEPATO CYTESINVIVO$EPENDINGONTHEMOUSEMODELUSED NAIVEORACTIVATED#$ 4 CELLSWEREEITHERSECLUDEDFROMRECOGNISINGTHEIRANTIGENONHEPATOCYTES ; = WHICHINDICATEDEFFICIENTBARRIERFUNCTIONBYSINUSOIDALCELLPOPU LATIONS OR WERE INCOMPLETELY STIMULATED ; = WHICH SUGGESTED DIRECT 4 CELL HEPATOCYTECONTACT#OLLECTIVELY THESERESULTSSUGGESTTHATINCASEOF INFECTIONWITHAHEPATOTROPICVIRUS PRESENTATIONOFVIRALANTIGENSBYHEPA TOCYTESWILLTRIGGERTHEINDUCTIONOFA#$4 CELLRESPONSE WHICHHOWEVER



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WILLBEINSUFFICIENTTOCLEARINFECTION)TISOFINTERESTTONOTETHATINTERACTION WITHRECENTLYPRIMED#$4 CELLSLICENSESHEPATOCYTESTOENGAGEINFURTHER INTERACTION WITH NAIVE #$ 4 CELLS ;= 4HIS WOULD ALLOW HEPATOCYTES TO ENGAGE IN IMMUNE REGULATION ONCE THE INITIAL TRIGGER FOR INDUCTION OF AN IMMUNERESPONSEHASBEENGIVENBYAPROFESSIONALANTIGEN PRESENTINGCELL POPULATION "ONE MARROW DERIVED ANTIGEN PRESENTING CELLS IN THE LIVER SUCH AS +UPFFERCELLSANDDENDRITICCELLS ALSOCONTRIBUTETOLOCALMODULATIONOFTHE IMMUNE RESPONSE IN THE LIVER +UPFFER CELLS INDUCE TOLERANCE RATHER THAN IMMUNITY;=4HISTOLEROGENICPHENOTYPEOF+UPFFERCELLSMAYBERELATED TOTHECONTINUOUSEXPOSURETOGUT DERIVED,03; =THATSTIMULATESPRO DUCTION OF THE IMMUNOREGULATORY CYTOKINE ),  IN +UPFFER CELLS ;= )N THEABSENCEOFASTRONGPROINFLAMMATORYSTIMULUSSUCHCONTINUOUSEXPRES SION OF ),  MAY PREVENT THE INITIATION OF 4 CELL RESPONSES BY THIS CELL POPULATION&URTHERMORE +UPFFERCELLSARENOTENDOWEDWITHTHEMOLECULAR MACHINERY TO PRESENT EXOGENOUS ANTIGENS ON -(# #LASS ) MOLECULES TO #$4 CELLS;=ANDTHEREFORECANNOTCONTRIBUTETOINDUCTIONOFVIRUS SPE CIFICIMMUNITY WHICHREQUIRESCROSS PRESENTATIONOFVIRALANTIGENSON-(# #LASS)MOLECULESTO#$4 CELLS;= (EPATIC DENDRITIC CELLS ARE A HETEROGENEOUS POPULATION CONSISTING OF MYELOID AND PLASMACYTOID DENDRITIC CELLS ;= 7HILE DENDRITIC CELLS ARE CONSIDEREDTOBEMOSTPOTENTININDUCING4 CELLIMMUNITYUPONAPPROPRIATE STIMULATION VARIOUSREPORTSHAVESHOWNTHATHEPATICDENDRITICCELLSDONOT UNDERGOFULLMATURATIONUPONCONTACTWITH4,2 LIGANDSANDSUBSEQUENTLY FAILTOINDUCESTRONG4 CELLIMMUNITY; =)TISLIKELYTHATCROSS PRESENTA TIONOFVIRALANTIGENSBYHEPATICDENDRITICCELLSALSOFAILSTOINDUCEVIRUS SPE CIFIC IMMUNITY AND RATHER PROMOTES INDUCTION OF ANTIGEN SPECIFIC IMMUNE TOLERANCE 3TELLATECELLSHAVEBEENFORMANYYEARSINTHEFOCUSOFRESEARCHONTHE MOLECULARMECHANISMSPROMOTINGHEPATICFIBROSIS;=!MONGTHESOLUBLE PROFIBROGENIC MEDIATORS RELEASED BY STELLATE CELLS IS THE POTENT IMMUNE REGULATORY CYTOKINE 4'&B "UT STELLATE CELLS DO NOT ONLY CONTRIBUTE AS BYSTANDERCELLSTOHEPATICIMMUNEREGULATIONBUTALSOHAVECELL AUTONOMOUS IMMUNE FUNCTIONS 4HEY CONSTITUTIVELY EXPRESS 4,2S AND ARE RESPONSIVE TO STIMULATION WITH ,03 WHICH ENDOWS THEM WITH SENTINEL FUNCTION ;= &URTHERMORE THEY BEAR THE CAPACITY TO PRESENT ANTIGENS ON -(# #LASS ) AND #$ MOLECULES TO #$ OR .+4 CELLS ;= (OWEVER STELLATE CELLS DO NOTHAVEPROMINENTSCAVENGERFUNCTION3CHURICHAND+NOLLE UNPUBLISHED OBSERVATION ANDTHEREFOREAREUNLIKELYTOCONTRIBUTETOTHECONTROLOF4 CELL RESPONSESDIRECTEDAGAINSTSOLUBLEVIRALANTIGENS !MONGTHEDIFFERENTANTIGEN PRESENTINGCELLPOPULATIONSINTHELIVER ,3%# APPEAR TO HAVE A PROMINENT ROLE BECAUSE THEY COMBINE EXTRAOR DINARY SCAVENGER ACTIVITY WITH ANTIGEN PRESENTING CAPACITY ; = 3CAVENGER FUNCTION OF ,3%# IS RELATED TO MOST EFFICIENT RECEPTOR MEDI ATEDENDOCYTOSISANDCONSTITUTIVEEXPRESSIONOFSCAVENGERRECEPTORSAND

4HELIVERASIMMUNEESCAPESITEFORPATHOGENS



VARIOUS PATTERN RECOGNITION RECEPTORS SUCH AS THE MANNOSE RECEPTOR # TYPELECTINSSUCHAS, 3)'. THEHYALURONICACIDRECEPTOR,96%  AND THEMEMBERSOFTHESTABILINFAMILY;  =4HISHIGHENDOCYTOTICACTIV ITYOF,3%#ISCOMBINEDWITHTHEIRABILITYTOPRESENTEXOGENOUSANTIGENS BOTHON-(##LASS))MOLECULESASWELLASON-(##LASS)MOLECULES !NTIGEN PRESENTATION ON CONSTITUTIVELY EXPRESSED -(# #LASS )) MOL ECULES TO #$4 CELLS IS NOT VERY EFFICIENT ;= BUT IN COMBINATION WITH CO STIMULATORYSIGNALINGTHROUGHLOWLEVELEXPRESSIONOF#$ALLOWS ,3%#TOPRIMENAIVE#$4 CELLS;=)MPORTANTLY #$4 CELLSPRIMED BY ANTIGEN PRESENTING ,3%# FAIL TO UNDERGO FUNCTIONAL MATURATION AND DONOTDEVELOPINTO4HEFFECTORCELLS;=4HESECELLSRATHEREXPRESS),  AND), UPONANTIGEN SPECIFICRESTIMULATIONANDTHEREFORELIKELYHAVE REGULATORYFUNCTIONFOROTHERIMMUNERESPONSES -ORE IMPORTANTLY ,3%# HAVE THE CAPACITY TO PRIME NAIVE #$ 4 CELLS TOWARDS SOLUBLE ANTIGENS PRESENTED ON -(# #LASS ) MOLECULES )N CONTRAST TO -(# #LASS )) RESTRICTED ANTIGEN PRESENTATION THE CROSS PRESENTATION OF EXOGENOUS ANTIGENS ON -(# #LASS ) MOLECULES TO #$ 4 CELLS IS VERY EFFICIENT IN ,3%# ;= "UT AGAIN #$4 CELLS PRIMED BY ANTIGEN PRESENTING ,3%# FAIL TO UNDERGO FUNCTIONAL DIFFERENTIATION AND RATHERGAINASTATEOFANERGYWHERETHEYDONOTRESPONDTOANTIGEN SPE CIFICRESTIMULATIONWITH4 CELLEFFECTORFUNCTIONSUCHASEXPRESSIONOF),  )&. aORCYTOTOXICITY;=4OLERANCEINDUCTIONBY,3%#TOWARDSSOLUBLE ANTIGENS PLAYS A ROLE IN TWO PHYSIOLOGICAL SITUATIONS I ORAL TOLERANCE UPONINGESTIONORALANTIGENSRAPIDLYSPREADINTHEENTIREORGANISMWITHIN MINUTES TO HOURS /RAL ANTIGENS ARE ALSO DISTRIBUTED TO THE LIVER WHERE THEYARECROSS PRESENTEDBY,3%##ROSS PRESENTATIONOFORALANTIGENSBY ,3%# LEADS TO INDUCTION OF #$4 CELL TOLERANCE TOWARDS ORAL ANTIGENS ;= AND THUS COMPLEMENTS THE INDUCTION OF REGULATORY #$4 CELLS BY TOLEROGENICDENDRITICCELLSWITHINMESENTERICLYMPHNODES;=II TOLER ANCE TOWARDS APOPTOTIC CELL MATERIAL TOGETHER WITH THE SPLEEN THE LIVER CONTRIBUTES TO REMOVAL OF APOPTOTIC CELLS FROM THE SYSTEMIC CIRCULATION ;n=7EHAVEREPORTEDTHATAPOPTOTICCELLMATERIALTAKENUPBY,3%# ISPROCESSEDFORANTIGENPRESENTATIONON-(##LASS)MOLECULESANDTHAT APOPTOTICCELLMATERIALTAKENUPINVIVOISSUFFICIENTTODRIVEANTIGEN SPE CIFIC4 CELLSTIMULATION;=(OWEVER THEOUTCOMEOF4 CELLSTIMULATIONIS AGAINTOLERANCE BECAUSE#$4 CELLSPRIMEDBY,3%#PRESENTINGANTIGEN FROM APOPTOTIC CELLS FAILED TO SHOW ANTIGEN SPECIFIC EFFECTOR FUNCTIONS ;=-ECHANISTICALLY TOLERANCEINDUCEDBY,3%#REQUIRESTHEDELIVERYOF CO INHIBITORYSIGNALSVIA"( 0$RECEPTOR LIGANDINTERACTIONTO4 CELLS DURING THE PRIMING PROCESS ;= $ESPITE INITIAL STIMULATION AND PROLIF ERATION TOLERANCEEVENTUALLYDEVELOPSIN,3%# STIMULATED4 CELLS WHICH EXPRESSANTIAPOPTOTICMOLECULESSUCHASBCL;=4HISDEMONSTRATESTHAT TOLERANCEINDUCEDBY,3%#ISANACTIVEPROCESSTHATDOESNOTRESULTFROM INSUFFICIENTSTIMULATIONBUTRATHERRELIESONDELIVERYOFCO INHIBITORYSIG NALS&URTHERMORE 4 CELLSAREANERGISEDANDNOTCLONALLYELIMINATEDAFTER



0ERCY!+NOLLEAND$IRK3TABENOW

CONTACTWITHANTIGEN PRESENTING,3%#;= WHICHISINCONTRASTTOCLONAL ELIMINATION OF4 CELLS OBSERVED AFTER4 CELL PRIMING BY TOLEROGENIC DEN DRITICCELLS;=4HESERESULTSSUGGESTTHAT,3%#CONTINUOUSLYSKEW#$ 4 CELL RESPONSES TOWARDS CIRCULATING ANTIGENS AND THEREBY CONTRIBUTE TO THECONTROLOFSELF REACTIVITYBYPREVENTINGAUTOIMMUNEREACTIONAGAINST APOPTOTIC CELL MATERIAL OR DEVELOPMENT OF IMMUNITY AGAINST INNOCUOUS ANTIGENSSUCHASFOODANTIGENS 4OLERANCEISNOTONLYACHIEVEDBYSKEWINGTHEFUNCTIONALREPERTOIREOF NAIVE#$4 CELLSBUTALSORESULTSFROMATTENUATIONOFEFFECTOR#$4 CELL FUNCTION +UPFFER CELLS AND ,3%# CONTRIBUTE TO ANTIGEN SPECIFIC RETEN TION AND ELIMINATION OF ACTIVATED #$ 4 CELLS IN THE LIVER ;n= 4HE CO INHIBITORYMOLECULE"(THATISEXPRESSEDON,3%#AND+UPFFERCELLS ALSO CONTRIBUTES TO ELIMINATION OF ACTIVATED #$ 4 CELLS IN THE LIVER ;= )NTERESTINGLY "( MEDIATEDELIMINATIONOF#$4 CELLSCONTRIBUTEDTOTHE DEVELOPMENTOFCHRONICITYOFVIRALINFECTIONINTHELIVER;=

4HELIVERASANIMMUNEESCAPESITEFORPATHOGENS 'IVEN THE TOLEROGENIC NATURE OF THE HEPATIC CELL POPULATIONS AND THE HEPATIC MICROENVIRONMENT IT IS NOT SURPRISING THAT THE LIVER FUNCTIONS AS ANIMMUNEESCAPESITEFORPATHOGENS4HESEQUENCEOFANTIGENENCOUNTER INLIVERORLYMPHATICTISSUEANDTHENATUREOFTHECELLTHATPRESENTSANTIGEN FIRSTTO#$4 CELLSDETERMINETHEOUTCOMEOFTHEANTIGEN SPECIFICIMMUNE RESPONSE4HISMEANSTHATINFECTIONOFTHELIVERWITHHEPATOTROPICVIRUSES WHICH ARE RAPIDLY TAKEN UP BY ,3%# AND WHICH INFECT HEPATOCYTES GIVES RISETOASITUATIONWHEREANTIGENISPRESENTEDBYTWOPROMINENTTOLEROGENIC CELLPOPULATIONSINTHELIVER)NITIALPRESENTATIONOFVIRALANTIGENSINTHELIVER COULDSKEWSUBSEQUENTVIRUS SPECIFICIMMUNERESPONSESFORACERTAINTIME PERIOD SO THAT ADDITIONAL MECHANISMS OF VIRAL PERSISTENCE SUCH AS WIDE SPREADHEPATOCELLULARINFECTIONOROTHERIMMUNEESCAPEMECHANISMSCOULD DEVELOP4HUS ,3%#MAYCONTRIBUTEATTWOSTAGESTOVIRALINFECTIONOFTHE LIVER FIRST IN ACUTE INFECTION WHERE SCAVENGING AND POSSIBLY TRANSCYTOSIS MAY SUPPORT LIVER SPECIFIC TARGETING OF HEPATOTROPIC VIRUSES AND FACILITATE HEPATOCYTE INFECTION AND SECOND DURING THE INITIAL AND LATER PHASES OF ANTIVIRALIMMUNERESPONSESWHERE,3%#MAYCONTRIBUTETOATTENUATIONOF VIRUS SPECIFIC #$4 CELL RESPONSES BY INDUCING VIRUS SPECIFIC #$4 CELL TOLERANCE

!CKNOWLEDGMENTS 4HE AUTHORS WISH TO THANK THE $&' AND THE6OLKSWAGENSTIFTUNG FOR CON TINUOUSFINANCIALSUPPORT

4HELIVERASIMMUNEESCAPESITEFORPATHOGENS



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 'REGORY 3( 7ING %*  .EUTROPHIL +UPFFER CELL INTERACTION IN HOST DEFENSESTOSYSTEMICINFECTIONS)MMUNOL4ODAYn  #LARK32 -A!# 4AVENER3! -C$ONALD" 'OODARZI: +ELLY-- 0ATEL+$ #HAKRABARTI 3 -C!VOY % 3INCLAIR '$ ET AL  0LATELET4,2 ACTIVATES NEUTROPHILEXTRACELLULARTRAPSTOENSNAREBACTERIAINSEPTICBLOOD.AT-ED n  3CHWABE 2& 3EKI % "RENNER $!  4OLL LIKE RECEPTOR SIGNALING IN THE LIVER'ASTROENTEROLOGYn  "OMSEL -  4RANSCYTOSIS OF INFECTIOUS HUMAN IMMUNODEFICIENCY VIRUS ACROSSATIGHTHUMANEPITHELIALCELLLINEBARRIER.AT-EDn  'EIJTENBEEK 4" +WON $3 4ORENSMA 2 VAN 6LIET 3* VAN $UIJNHOVEN '# -IDDEL * #ORNELISSEN ), .OTTET (3 +EWAL2AMANI 6. ,ITTMAN $2 ET AL  $# 3)'. ADENDRITICCELL SPECIFIC()6  BINDINGPROTEINTHATENHANCES TRANS INFECTIONOF4 CELLS#ELLn  $OTZAUER! "RENNER- 'EBHARDT5 6ALLBRACHT! )G! COATEDPARTICLES OF (EPATITIS! VIRUS ARE TRANSLOCALIZED ANTIVECTORIALLY FROM THE APICAL TO THE BASOLATERALSITEOFPOLARIZEDEPITHELIALCELLSVIATHEPOLYMERICIMMUNOGLOBULIN RECEPTOR*'EN6IROLn  3HIN3# 6ANDERBERG*0 4ERZAKIS*! $IRECTINFECTIONOFHEPATOCYTESBY SPOROZOITESOF0LASMODIUMBERGHEI*0ROTOZOOLn  0RADEL' &REVERT5 -ALARIASPOROZOITESACTIVELYENTERANDPASSTHROUGH RAT+UPFFERCELLSPRIORTOHEPATOCYTEINVASION(EPATOLOGYn  -OTA -- 0RADEL ' 6ANDERBERG *0 (AFALLA *# &REVERT 5 .USSENZWEIG 23 .USSENZWEIG 6 2ODRIGUEZ !  -IGRATION OF 0LASMODIUM SPOROZOITES THROUGHCELLSBEFOREINFECTION3CIENCEn  3CHLEPPER 3CHAFER* (ULSMANN$ $JOVKAR! -EYER(% (ERBERTZ, +OLB( +OLB "ACHOFEN6  %NDOCYTOSIS VIA GALACTOSE RECEPTORS IN VIVO ,IGAND SIZEDIRECTSUPTAKEBYHEPATOCYTESANDORLIVERMACROPHAGES%XP#ELL2ES n  3MEDSROD "  #LEARANCE FUNCTION OF SCAVENGER ENDOTHELIAL CELLS #OMP (EPATOL3UPPL3  "REINER+- 3CHALLER( +NOLLE0! %NDOTHELIALCELL MEDIATEDUPTAKEOF AHEPATITIS"VIRUSANEWCONCEPTOFLIVERTARGETINGOFHEPATOTROPICMICROORGAN ISMS(EPATOLOGYn  ,IMMER! /HL* +URTS# ,JUNGGREN(' 2EISS9 'ROETTRUP- -OMBURG& !RNOLD " +NOLLE 0!  %FFICIENT PRESENTATION OF EXOGENOUS ANTIGEN BY LIVER ENDOTHELIAL CELLS TO #$4 CELLS RESULTS IN ANTIGEN SPECIFIC4 CELL TOLER ANCE.AT-EDn  *ILBERT!2 -ILLER$3 3COUGALL#! 4URNBULL( "URRELL#* +INETICSOF DUCKHEPATITIS"VIRUSINFECTIONFOLLOWINGLOWDOSEVIRUSINOCULATIONONEVIRUS $.!GENOMEISINFECTIOUSINNEONATALDUCKS6IROLOGYn  'EUZE(* 3LOT*7 3TROUS'* 0EPPARD* VON&IGURA+ (ASILIK! 3CHWARTZ!,  )NTRACELLULARRECEPTORSORTINGDURINGENDOCYTOSISCOMPARATIVEIMMUNO ELECTRONMICROSCOPYOFMULTIPLERECEPTORSINRATLIVER#ELLn  7ANG% "ROWN03 !ROETI" #HAPIN3* -OSTOV+% $UNN+7 !PICAL AND BASOLATERAL ENDOCYTIC PATHWAYS OF -$#+ CELLS MEET IN ACIDIC COMMON

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ENDOSOMESDISTINCTFROMANEARLY NEUTRALAPICALRECYCLINGENDOSOME4RAFFIC n ,EUNG3- 2UIZ7' !PODACA' 3ORTINGOFMEMBRANEANDFLUIDATTHE APICAL POLE OF POLARIZED -ADIN $ARBY CANINE KIDNEY CELLS -OL "IOL #ELL  n 4UMA0, (UBBARD!, 4RANSCYTOSISCROSSINGCELLULARBARRIERS0HYSIOL 2EVn )HRKE' -ARTIN'6 3HANKS-2 3CHRADER- 3CHROER4! (UBBARD!, !PICALPLASMAMEMBRANEPROTEINSANDENDOLYN TRAVELTHROUGHASUBAPICAL COMPARTMENTINPOLARIZED7)& "HEPATOCYTES*#ELL"IOLn 2OJAS2 !PODACA' )MMUNOGLOBULINTRANSPORTACROSSPOLARIZEDEPITHE LIALCELLS.AT2EV-OL#ELL"IOLn "REITFELD 00 (ARRIS *- -OSTOV +%  0OSTENDOCYTOTIC SORTING OF THE LIGAND FOR THE POLYMERIC IMMUNOGLOBULIN RECEPTOR IN -ADIN $ARBY CANINE KIDNEYCELLS*#ELL"IOLn "OMSEL - (EYMAN - (OCINI ( ,AGAYE 3 "ELEC , $UPONT # $ESGRANGES # )NTRACELLULARNEUTRALIZATIONOF()6TRANSCYTOSISACROSSTIGHTEPITHELIAL BARRIERSBYANTI ()6ENVELOPEPROTEIND)G!OR)G-)MMUNITYn 'HETIE6 7ARD%3 -ULTIPLEROLESFORTHEMAJORHISTOCOMPATIBILITYCOM PLEXCLASS) RELATEDRECEPTOR&C2N!NNU2EV)MMUNOLn )SRAEL %* 4AYLOR 3 7U : -IZOGUCHI % "LUMBERG 23 "HAN! 3IMISTER .%  %XPRESSIONOFTHENEONATAL&CRECEPTOR &C2N ONHUMANINTESTINALEPI THELIALCELLS)MMUNOLOGYn $ICKINSON ", "ADIZADEGAN + 7U : !HOUSE *# :HU 8 3IMISTER .% "LUMBERG23 ,ENCER7) "IDIRECTIONAL&C2N DEPENDENT)G'TRANSPORT INAPOLARIZEDHUMANINTESTINALEPITHELIALCELLLINE*#LIN)NVESTn +EMPKA ' +OLB "ACHOFEN 6  "INDING UPTAKE AND TRANSCYTOSIS OF LIGANDS FOR MANNOSE SPECIFIC RECEPTORS IN RAT LIVER AN ELECTRON MICROSCOPIC STUDY%XP#ELL2ESn 3IMIONESCU- 3IMIONESCU. %NDOTHELIALTRANSPORTOFMACROMOLECULES TRANSCYTOSISANDENDOCYTOSIS!LOOKFROMCELLBIOLOGY#ELL"IOL2EVn 3HANNON ,OWE #$ .EUHIERL " "ALDWIN ' 2ICKINSON !" $ELECLUSE (*  2ESTING"CELLSASATRANSFERVEHICLEFOR%PSTEIN "ARRVIRUSINFECTIONOF EPITHELIALCELLS0ROC.ATL!CAD3CI53!n !LVAREZ#0 ,ASALA& #ARRILLO* -UNIZ/ #ORBI!, $ELGADO2 # TYPE LECTINS$# 3)'.AND, 3)'.MEDIATECELLULARENTRYBY%BOLAVIRUSINCISAND INTRANS*6IROLn 4ASSANEETRITHEP " "URGESS4( 'RANELLI 0IPERNO! 4RUMPFHELLER # &INKE * 3UN7 %LLER-! 0ATTANAPANYASAT+ 3ARASOMBATH3 "IRX$,ETAL $# 3)'.#$ MEDIATESDENGUEVIRUSINFECTIONOFHUMANDENDRITICCELLS*%XP -EDn +LIMSTRA7" .ANGLE%- 3MITH-3 9UROCHKO!$ 2YMAN+$ $# 3)'.AND, 3)'.CANACTASATTACHMENTRECEPTORSFORALPHAVIRUSESANDDISTIN GUISHBETWEENMOSQUITOCELL ANDMAMMALIANCELL DERIVEDVIRUSES*6IROL n "ASHIROVA!! 'EIJTENBEEK4" VAN$UIJNHOVEN'# VAN6LIET3* %ILERING*" -ARTIN-0 7U, -ARTIN4$ 6IEBIG. +NOLLE0!ETAL !DENDRITICCELL







 

  

















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#GENOTYPEINFECTIONINCOMBINATIONWITHPEGYLATEDINTERFERONWITHAND WITHOUT RIBAVIRIN IN PATIENTS WHO DO NOT RESPOND TO PEGYLATED INTERFERON ANDRIBAVIRINCOMBINATION&ASTTRACKDESIGNATIONWASGRANTEDBYTHE&$! ;=

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/LAF7EBER

 $EPRAETERE 3 ,EROUX 2OELS '  (EPATITIS # VIRUS ENVELOPE PROTEINS IMMUNOGENICITY IN HUMANS AND THEIR ROLE IN DIAGNOSIS AND VACCINE DEVELOP MENT6IRAL(EPAT2EVn  #OMPANYPRESSRELEASEON-AY  #OMPANY WEBSITE AT HTTPWWWENZOCOMTHERAPEUTICSPRODUCT?PIPELINEASP RETRIEVEDON!UGUST  HTTPCLINICALTRIALSGOVCTSHOW.#4 RETRIEVEDON!UGUST  #OMPANY WEBSITE ATHTTPWWWMAXYGENCOMPRODUCTS HEPPHP RETRIEVED ON !UGUST  0OCKROS0* 'UYADER$ 0ATTON( 4ONG-* 7RIGHT4 -C(UTCHISON*' -ENG 4# /RALRESIQUIMODINCHRONIC(#6INFECTION3AFETYANDEFFICACYIN PLACEBO CONTROLLED DOUBLE BLINDPHASE))ASTUDIES*(EPATOLn  #OMPANYWEBSITEATHTTPWWWARROWTCOUKPRODUCT HCVASP RETRIEVEDON !UGUST  #OMPANY WEBSITE AT HTTPWWWAVIBIOCOMPRPRHTML RETRIEVED ON  !UGUST  #OMPANY WEBSITE AT HTTPWWWBIOENVISIONCOMPRODUCTS?PIPELINEPHP RETRIEVEDON!UGUST  +AITA+ 0HASE))STUDYOF#ELGOSIVIRINCOMBINATIONWITHPEGINTERFERON ALFA BANDRIBAVIRININCHRONICHEPATITIS#GENOTYPE NON RESPONDERPATIENTS PRESENTATION AT THE $IGESTIVE $ISEASE7EEK n -AY  n7ASHINGTON $#  -EALY.% ,UPONE" 4ELL- $RUGSUNDERDEVELOPMENTFORTHETREAT MENTOFHEPATITIS$RUGS&UTn  9OO"# +IM*( +IM4( +OH+# 5M3( +IM93 ,EE+3 (AN"( #HON #9 (AN*9ETAL #LEVUDINEISHIGHLYEFFICACIOUSINHEPATITIS"EANTI GEN NEGATIVE CHRONIC HEPATITIS " WITH DURABLE OFF THERAPY VIRAL SUPPRESSION (EPATOLOGY n  9OO "# +IM *( #HUNG9( ,EE +3 0AIK 37 2YU 3( (AN "( (AN *9 "YUN +3 #HO - ET AL  4WENTY FOUR WEEK CLEVUDINE THERAPY SHOWED POTENTANDSUSTAINEDANTIVIRALACTIVITYIN("E!G POSITIVECHRONICHEPATITIS" (EPATOLOGYn  &LISIAK2 (ORBAN! +IERKUS* 3TANCZAK* #IELNIAK) 3TANCZAK'0 7IERCINSKA $RAPALO! 3IWAK% (IGERSBERGER* !ESCHLIMANN#ETAL 4HECYCLOPHILIN INHIBITOR $%")/  HAS A POTENT DUAL ANTI ()6 AND ANTI (#6 ACTIVITY IN TREATMENT NAÕVE()6(#6CO INFECTEDSUBJECTS!MERICAN!SSOCIATIONFORTHE 3TUDYOF,IVER$ISEASES!!3,$ "OSTON n/CTOBER  #OMPANY WEBSITE AT HTTPWWWGILEADCOMANTIVIRAL RETRIEVED ON  !UGUST   #OMPANY WEBSITE AT HTTPPHXCORPORATE IRNETPHOENIXZHTMLCP IROL RESEARCH.EWS!RTICLE)$HIGHLIGHT RETRIEVED ON  !UGUST   #OMPANYPRESSRELEASE  7ATASHI + 3HIMOTOHNO +  #HEMICAL GENETICS APPROACH TO HEPATITIS # VIRUSREPLICATIONCYCLOPHILINASATARGETFORANTI HEPATITIS#VIRUSSTRATEGY2EV -ED6IROLn  3TUYVER ,* -C"RAYER 42 4HRANISH 0- #LARK * (OLLECKER , ,OSTIA 3 .ACHMAN4 'RIER * "ENNETT -! 8IE - 9 ET AL  )NHIBITION OF HEPA

$RUGCANDIDATESFORTHETREATMENTOFVIRALHEPATITIS



 

               





TITIS # REPLICON 2.! SYNTHESIS BY ` $  DEOXY  FLUORO  METHYLCYTIDINE ! SPECIFIC INHIBITOR OF HEPATITIS # VIRUS REPLICATION !NTIVIRAL #HEMISTRY AND #HEMOTHERAPYn -URAKAMI% "AO( 2AMESH- -C"RAYER42 7HITAKER4 -ICOLOCHICK3TEUER (- 3CHINAZI 2& 3TUYVER ,* /BIKHOD! /TTO -* ET AL  -ECHANISM OF ACTIVATION OF ["ETA] $  DEOXY  FLUORO  # METHYLCYTIDINE AND INHIBI TION OF HEPATITIS # VIRUS .3" 2.! POLYMERASE !NTIMICROBIAL !GENTS AND #HEMOTHERAPY n #OMPANY WEBSITE AT HTTPWWWPHARMASSETCOMPIPELINEPSI ASP RETRIEVEDON!UGUST #OMPANY WEBSITE AT HTTPWWWROCHECOMHOMEINVESTORSINV? PIPELINEINV? PIPELINE?DETHTMTA6IROLOGY0HASESUBMIT3HOWPIPELINERETRIEVED ON!UGUST HTTPWWWCLINICALTRIALSGOVCTSHOW.#4ORDER RETRIEVED ON  !UGUST #OMPANY WEBSITE AT HTTPWWWGLOBEIMMUNECOMINDEXPHP LOADNEWS PAGEINDEXOPNEWS?VIEWNEWS?ID RETRIEVEDON!UGUST HTTPWWWCLINICALTRIALSGOVCTSHOW.#4ORDER RETRIEVED ON  !UGUST 6ERTEXPRESSRELEASE*ANUARY #OMPANY WEBSITE AT HTTPWWWUNITHERCOMPRODUCTS?GLYBOASP RETRIEVED ON !UGUST #OMPANYPRESSRELEASE*ULY +EEFFE%" -ARCELLIN0 .EWANDEMERGINGTREATMENTOFCHRONICHEPATI TIS"#LIN'ASTROENTEROL(EPATOLn #OMPANYWEBSITEATHTTPWWWVIROCHEMPHARMACOMOUR&OCUSHTMLRETRIEVED ON!UGUST HTTPWWWCLINICALTRIALSGOVCTSHOW.#4ORDER RETRIEVED ON  !UGUST #OMPANY WEBSITE AT HTTPWWWSCHERING PLOUGHCOMPDFPRODUCTPIPELINEPDF RETRIEVEDON!UGUST #OMPANY WEBSITE AT HTTPWWWVALEANTCOMRESEARCH!ND$EVELOPMENTPIPE LINETARIBAVIRINJSPFRETRIEVEDON!UGUST #OMPANY WEBSITE AT HTTPWWWCELLDEXTHERAPEUTICSCOMWTPAGECDX? RETRIEVEDON!UGUST #OMPANY WEBSITE AT HTTPWWWDYNAVAXCOMHEPATITIS?BPREVHTM RETRIEVED ON!UGUST #OMPANYWEBSITEATHTTPWWWPEVIONCOMINDEXPHPPAGE RETRIEVEDON !UGUST #OMPANY WEBSITE AT HTTPWWWINTERCELLCOAT3ELECT-ENUWASE)$- CCCBA  FE AC BAA RETRIEVEDON!UGUST &IRBAS #H *ILMA " 4AUBER % "UERGER6 *ELOVCAN 3 ,INGNAU + "USCHLE - &RISCH * +LADE #H  )MMUNOGENICITY AND SAFETY OF A NOVEL THERAPEUTIC HEPATITIS#VIRUS(#6 PEPTIDEVACCINEARANDOMIZED PLACEBOCONTROLLEDTRIAL FORDOSEOPTIMIZATIONINHEALTHYSUBJECTS6ACCINEn #OMPANY WEBSITE AT HTTPWWWGSKCOMINVESTORSPP?PIPELINE?STANDARDHTM RETRIEVEDON!UGUST

)NDEX

!   ACETAMINOPHEN  !CKERTIAMARMOTAE  ACUTEPHASEPROTEIN  ACYCLOVIR  ADAPTIVEIMMUNITY  ADEFOVIR    ADENOVIRUS  AmATOXIN"  ALANINEAMINOTRANSFERASE!,!4   ALBUMIN UROKINASETYPEPLASMINOGEN ACTIVATORU0! TRANSGENICMOUSE  ALCOHOLINDUCEDLIVERCIRRHOSIS  ALCOHOLICSTEATOHEPATITIS!3(  ALKALINEPHOSPHATASE!0  ALPHA ANTITRYPSINDElCIENCY   ALPHA INTERFERON  AMINOACID SERUMCONCENTRATION  AMMONIA DETOXIlCATION  !.!   ANIMALMODEL n    ANTHROPOZOONOSIS  ANTIMICROBIALDRUG  !0/"%#PROTEIN  ARA !-0  ARCTICSQUIRRELHEPATITISVIRUS!3(6   !RMILLIFER   ASCITES  ASPARTATEAMINOTRANSFERASE!3!4   ASSOCIATEDAUTOIMMUNEDISEASE  AUTOIMMUNEHEPATITIS!)(   AUTOIMMUNELIVERDISEASE   !6)   AVIHEPADNAVIRUS  !:4  BACTERIALABSCESS  BACTERIALHEPATITIS  BACTERIALHEPATITIS EQUINE 

"ARTONELLAHENSELAE  BAVITUXIMAB  BILEACID  BILIRUBIN UNCONJUGATED  ")6.   BLOODCOAGULATION  BLUE GREENALGAETOXIN  "RUCELLA  "URKHOLDERIAPSEUDOMALLEI  CALICIVIRUS  #ANINE!DENOVIRUS#!6    #APILLARIASP  #APILLARIAHEPATICA n CARBOXYPEPTIDASE$  CARCINOMA HEPATOCELLULAR  CARPROFEN  ` CATENIN  CELGOSIVIR  CELLCULTURE  n CELLULARIMMUNERESPONSE  CELLULARRESTRICTIONFACTOR   CHIMERICMOUSEMODEL  CHIMERICVIRUS  CHIPMUNK  CHOLANGIOHEPATITIS  CHOLELITHIASIS  CHOLESTASIS   CHRONICACTIVEHEPATITIS  #ICAVIR  CLEVUDINE   #LONORCHISSINENSIS n C MYC  COMBINATIONTHERAPY  #/--$GENE  COMPARATIVEMEDICINE  COPPERMETABOLISM    COPPERSTORAGE  COREPROTEIN   COVALENTLYCLOSEDCIRCULAR$.! CCC$.!      CRANEHEPATITIS"VIRUS 



CREATININE  CYCLOPHOSPHAMIDE  CYTOKINE   CYTOMEGALOVIRUS#-6     $$" 3  $%")/   DENGUEFEVERVIRUS  $ICROCOELIUMDENDRITICUM n DIETHYLNITROSAMINE$%.  DIFFERENTIALDIAGNOSIS  DIHYDROARYLPYRIMIDINE   CCC$.!      RC$.!  DRUG INDUCEDLIVERDISEASE   DUCKHEPATITIS"VIRUS$("6    %CHINOCOCCUSGRANULOSUS n  %CHINOCOCCUSMULTILOCULARIS n %$  %(#  %(4  ELECTRONMICROSCOPY   EMTRICITABINE  ENDOCYTOSIS  %NTAMOEBAHISTOLYTICA n ENTECAVIR    %NTEROBACTERIACEAE   %NTEROCOCCUS  ENTEROVIRUS  ENVELOPEPROTEIN   %PSTEIN "ARRVIRUS%"6     EQUINEVIRALHEPATITIS   %UTAMIAS  FAMCICLOVIR  &ASCIOLAHEPATICA n   FATTYLIVER  lALURIDINE  lBRINOGEN  lBROPLASIA   lBROSINGCHOLESTATICHEPATITIS&#(  &LAVIVIRIDAEFAMILY  FOCALNECROTISINGPATTERN  &RANCISELLATULARENSIS  GAMMAGLUTAMYLTRANSFERASEa'4  '"VIRUS!AND"'"6 !'"6 "  GLOMERULONEPHRITIS IMMUNE MEDIATED  GLUCOCORTICOID  GLUCOSE SERUMCONCENTRATION  GLUTAMATEDEHYDROGENASE',$( 

)NDEX

GLYCOPROTEIN    GRADING   GRANULOMATOUSBACTERIALHEPATITIS   GRANULOMATOUSINmAMMATION  GROUNDSQUIRRELHEPATITISVIRUS'3(6      GROUND GLASSHEPATOCYTE  '3   HAEMATOLOGY  HAEMOCHROMATOSIS   HELIOXANTHIN  HEPADNAVIRALHOSTRANGE MOLECULARBA SIS  HEPADNAVIRALINFECTIVITY  HEPADNAVIRUS n HEPADNAVIRUS CROSS SPECIESTRANSMISSI ON  HEPADNAVIRUS INFECTIOUSCYCLE  HEPADNAVIRUS INFECTIVITYTESTING   HEPADNAVIRUS PHYLOGENY   HEPADNAVIRUSHOST NATURAL  HEPADNAVIRUSHOST PHYLOGENY n HEPATICENCEPHALOPATHY(%         HEPATICFUNCTIONTEST   HEPATICGRANULOMA  HEPATICPROGENITORCELL  HEPATICSTELLATECELL(3#  HEPATITIS ACUTE    HEPATITIS ACUTE INDOGS n HEPATITIS BACTERIALANDPARASITIC   HEPATITIS CHRONIC n HEPATITIS CHRONIC INDOGS n HEPATITIS COPPER RELATED  HEPATITIS FULMINANT  HEPATITIS ISCHAEMIC   HEPATITIS MONONUCLEOSIS LIKE  HEPATITIS TOXIC   HEPATITIS VIRAL n  HEPATITIS VIRAL DIAGNOSIS n HEPATITIS VIRAL DIAGNOSTICALGORITHM  HEPATITIS!  n HEPATITIS! SYMPTOMS  HEPATITIS!VIRUS(!6     n  (!6 INTERNATIONAL6IRUS#ODE  (!6 PATHOGENESIS   (!6 VIRUSSTABILITY  (!6ANTIGEN  (!6HYPERIMMUNOGLOBULIN  (!6TRANSMISSION    (!6VACCINE  HEPATITIS" CHRONIC 

)NDEX

HEPATITIS"SURFACEANTIGEN("S!G    ("E!G  n HEPATITIS"TREATMENT   HEPATITIS"VIRUS("6      n n   ("6CAPSID n ("6 PRE3 DERIVEDPEPTIDE  HEPATITIS#TREATMENT n HEPATITIS#VIRUS(#6       (#6 2.!REPLICATION n  (#6 TRANSMISSIONOF   (#6DIAGNOSIS  (#6GENOME   (#6PARTICLE ANATOMY  (#6PARTICLEASSEMBLY n  (#6PERSISTENCE  (#6PSEUDOPARTICLE(#6PP  (#6   HEPATITIS$  HEPATITIS$VIRUS($6       HEPATITISDRUG n HEPATITIS%  n HEPATITIS%INCUBATION   HEPATITIS%VIRUS(%6      n  (%6 INTERNATIONAL6IRUS#ODE  (%6REPLICATION  HEPATITISEPIDEMICA  HEPATITIS'VIRUS'"6 #('6   HEPATITISTREATMENT HORSE n HEPATITISVACCINE n HEPATOCARCINOGENESIS n HEPATOCELLULARBURNEDOUTPHENOMENON  HEPATOCELLULARCARCINOMA(## n  HEPATOTOXICCHEMICALS  (EPATOVIRUS   (EPEVIRIDAE  HEREDITARYLIVERDISEASE  HERONHEPATITIS"VIRUS(("6    HERPESSIMPLEXVIRUS(36     HOSTDETERMININGREGION  HOSTRANGE n HOSTRANGE EXPERIMENTALASSESSMENT  HOSTRANGE MOLECULARDETERMINANT  HYDATID  HYDATIDCYST  HYPERGLOBULINAEMIA  HYPOALBUMINAEMIA 



),   IMMUNERESPONSE   IMMUNOMODULATORYAGENT  INFECTIOUSHEPATITIS  )../  )../   INTERFERON)&. n  n INTERFERON _)&. _   INTERFERON a)&. a    INTERFERONOMEGA  )NTERNATIONAL#OMMITTEEON4AXONOMYOF 6IRUSES)#46  INTESTINALEPITHELIA  INTRAVASCULARCOAGULATION  )SHAKSMODIlEDHISTOLOGICALACTIVITYINDEX M(!)   )4-.   *APANESEPATIENTWITHFULMINANTHEPATITIS *&(    +UPFFERCELL   +UPFFERCELLACTIVATION  LACTULOSE  LAMIVUDINE   LAPAROSCOPY  LARGEENVELOPEPROTEIN  ,EISHMANIA n ,EPTOSPIRAICTEROHAEMORRHAGIAE  LEPTOSPIROSIS   LIFEEXPECTANCY  ,INGUATULA   LIPOGRANULOMA  ,ISTERIAMONOCYTOGENES  LIVERBIOPSY  n LIVERBIOPSYSCORE  LIVERCIRRHOSIS n     LIVERCONSENSUSGROUP  LIVERENZYME  LIVERmUKE  LIVERPROGENITORCELL  LIVERSINUSOIDALENDOTHELIALCELL ,3%# n n LIVERTRANSPLANTATION  , ORNITHINE , ASPARTATE  MALARIA   n -ALLORYSHYALINENUCLEI  METABOLICLIVERDISEASE  -%4!6)2  METRONIDAZOLE  MOUSEMODEL  MULTISYSTEMICEOSINOPHILICEPITHELIOTROPHIC DISEASE-%%$ 



-YCOBACTERIUMTUBERCULOSIS  MYCOPHENOLATEMOFETIL--&  MYRISTOYLATION  . ACETYLCYSTEINE  NALIDIXINEACID  .EISSERIAGONORRHOEAE  .EISSERIAMENINGITIDIS   NEOMYCIN  NEPHROTICSYNDROME  .& g"  NITRICOXIDE./   . MYC  . MYCLOCUS   NON ALCOHOLICSTAETOHEPATITIS.!3(    NUCLEOSIDEANALOG   ONCOGENE  /PISTHORCHIS n ORTHOHEPADNAVIRUS  OXIDATIVEDAMAGE   0ARASCARISEQUORUM  0EGASYS  PEGYLATEDINTERFERON _0%' )&._   PENICILLAMINE   PERICELLULARlBROSIS  PHYLOGENETICTREE BIRDS  PHYLOGENETICTREE MAMMALS  0ICORNAVIRIDAE   0LASMODIUM   n POLYMERASE ("6   0OROCEPHALUS   PORTOSYSTEMICACQUIREDCOLLATERAL  PREDNISOLONE  PREGENOMIC2.!PG2.!   PREGNANCY   PRENEOPLASTICFOCUS  PRIMARYBILIARYCIRRHOSIS0"#   PRIMARYSCLEROSINGCHOLANGITIS03#   PROGENITORCELL  PROTOZOAN  PSEUDOTYPING  PULMONARYMETASTASE  2   2   2   2    REGULATORY4 CELL4REG  RELAXEDCIRCULAR$.!RC$.! 

)NDEX

RC$.!INHEPADNAVIRALREPLICATION  REPLICASE    REPLICONSYSTEM  RESIQUIMOD  RETROPOSON  REVERSETRANSCRIPTION24  RIBAVIRIN   2.! PREGENOMICPG2.!   2.! SHORTHAIRPINSH2.!  2.! SMALLINTERFERINGSI2.!  2.!POLYMERASE  2OSSSGOOSEHEPATITIS"VIRUS 2'("6   RUBEANICACIDSTAIN   SANDEDNUCLEI  3CH    3CHISTOSOMA   n 3#)$MOUSE  SERUMENZYMES   SERUMHEPATITIS  SHORTHAIRPIN2.!SH2.!  SILYMARIN  SMALLINTERFERING2.!SI2.!  SMALLMOLECULETREATMENT  SNOWGOOSEHEPATITIS"VIRUS3'("6   STAGING    3TAPHYLOCOCCUS  STEATOHEPATITIS  STORKHEPATITIS"VIRUS34("6  3TREPTOCOCCUS  3TRONGYLUS  SULFONAMIDE  SUSTAINEDVIROLOGICRESPONSE362  TARIBAVIRIN  4 CELLRECEPTOR  4 CELLRESPONSE   TELAPREVIR  TELBIVUDINE  TENOFOVIR   TENOFOVIRDISOPROXILFUMARATE  4HEILERSDISEASE  TISSUETROPISM  TRANSCYTOSIS n TRANSGENICMOUSESTRAIN EXPRESSING("6 GENOME  TRAVELLERSHEPATITIS  4REPONEMAPALLIDIUM  4RYPANOSOMACRUZI n ULTRASONOGRAPHY   U0!3#)$MOUSE 

)NDEX

UREA INSERUM  54 "  VALOPICITABINE  VALTORCITABINE  VARICELLAZOSTERVIRUS6:6    6#(   VERY LOW DENSITYLIPOPROTEIN6,$,   6'8 #  VIRALHEPATITIS EQUINE   VIRALINFECTION PERMISSIVITYANDRESTRICTION FACTORS   VIRALINTEGRATION  VIRALPOLYMERASE  7(COREANTIGEN7(C!G  WHITESTORKHEPATITIS"VIRUS73("6 



7(6SURFACEANTIGEN7(S!G  7(6. MYCTRANSGENE  7(8PROTEIN  7ILSONDISEASE  WITHDRAWALTREATMENT  WOODCHUCKHEPATITISVIRUS7(6    n WOOLLYMONKEYHEPATITIS"VIRUS 7-("6    8GENE  ZINCGLUCONATE  ZONALPATTERN LIVERACINUS  ZONE COPPERACCUMULATIONINLIVER LOBULES 

4HE"!)$ 3ERIES "IRKHËUSER!DVANCESIN)NFECTIOUS$ISEASES )NFECTIOUS DISEASES REMAIN A SUBSTANTIAL DRAIN ON HUMAN WELL BEING AND ECONOMIESDESPITETHEAVAILABILITYOFMODERNDRUGS.EWPATHOGENSEMERGE AND KNOWN PATHOGENS CHANGE THEIR GEOGRAPHICAL DISTRIBUTION AND THEIR SUSCEPTIBILITYTOTHEAVAILABLEDRUGS!NUNDERSTANDINGOFTHESTRUCTUREAND FUNCTIONOFINFECTIOUSDISEASEPATHOGENSISAMAJORSCIENTIFICCHALLENGEWITH IMPORTANTPOTENTIALAPPLICATIONS 4HIS NEW CROSS DISCIPLINARY MONOGRAPH SERIES WILL PROVIDE UP TO DATE INFORMATIONONTHELATESTDEVELOPMENTSININFECTIOUSDISEASERESEARCH4HE MULTI AUTHOREDVOLUMESWILLCOVERBASICBIOLOGYANDBIOCHEMISTRYOFPATHO GENSASWELLASAPPLIEDMEDICALASPECTSANDIMPLICATIONSFORPUBLICHEALTH ANDPOLICY 4HECONTRIBUTIONSAREWRITTENBYLEADINGINFECTIOUSDISEASERESEARCHERS ANDPHARMACEUTICALSCIENTISTSWITHAWIDERANGEOFEXPERTISE 4HEENVISAGEDREADERSHIPINCLUDESACADEMICANDINDUSTRIALRESEARCHERS INMEDICINEANDINFECTIOUSDISEASESASWELLASCLINICIANSANDOTHERSINVOLVED INDIAGNOSTICSANDDRUGDEVELOPMENT

!VAILABLEVOLUMES #ORONAVIRUSES WITH 3PECIAL %MPHASIS ON &IRST )NSIGHTS #ONCERNING 3!23 !3CHMIDT -(7OLFF /7EBER%DITORS  4HE'RAND#HALLENGEFORTHE&UTURE6ACCINESFOR0OVERTY 2ELATED$ISEASES FROM "ENCH TO &IELD 3(% +AUFMANN AND 0 ( ,AMBERT %DITORS  #OMMUNITY !CQUIRED0NEUMONIA .3UTTORP 47ELTE 2-ARRE%DITORS  0OXVIRUSES !-ERCER !3CHMIDT /7EBER%DITORS  0EDIATRIC )NFECTIOUS $ISEASES 2EVISITED ( 3CHROTEN 3 7IRTH %DITORS  )NFLUENZA6ACCINESFORTHE&UTURE 22APPUOLI%DITOR